Healthcare Approved Services Form

Healthcare Approved Services Form

Patient Name:    Medical Record Number:

Date of Request:    Facility / Clinic:

Patient Information

Insurance Information

Medical / Clinical Information

Approved Services (Itemized)

Service 1

Service 2

Service 3 (Optional)

Clinical Justification & Administrative Conditions

The services listed above are approved on the basis of the documented clinical need and supporting records provided by the treating clinician. Approval is conditional and may be subject to modification if additional clinical information indicates a change in the medical necessity determination. Approvals are limited to the service descriptions, codes, frequencies and date ranges expressly set forth in this form.

By initialing and checking the boxes below, the patient confirms these statements were communicated and acknowledged:

  I acknowledge that alternative treatment options and reasonable alternatives were discussed with me and that I had an opportunity to ask questions.

  I acknowledge that this approval is limited by clinical criteria, prior authorization conditions, and payer policy, and that approval does not, by itself, guarantee payment.

Financial and Billing Terms

Patient Financial Responsibility: The patient remains responsible for any applicable co-payments, deductibles, coinsurance, charges for non-covered services, and charges assessed by out-of-network providers. Authorization of services is an administrative determination and is not a guarantee of payment from any payer. Billing disputes and coverage determinations remain subject to insurer terms and appeals.

HIPAA & Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the provider's notice of privacy practices describing the uses and disclosures of my protected health information. I understand that information necessary to process and coordinate approval of services will be disclosed to payer(s), treating providers, and applicable review entities as required for utilization review and billing.

  I acknowledge receipt of the privacy practices notice and consent to the uses and disclosures described above.

Authorization Term, Revocation, and Appeals

Authorization Expiration Date:

This authorization will expire on the date shown above or upon exhaustion of approved units, whichever occurs first. The patient or authorized representative may revoke this authorization in writing; revocation will not affect actions taken in reliance on this authorization prior to receipt of revocation. If services are denied or modified, the patient may pursue the payer's administrative appeal processes as provided in the payer's coverage policies.

Provider Attestation

Provider attests that the clinical information contained in this request is accurate and complete to the best of their knowledge and that the requested services are reasonable and necessary for the treatment of the patient.

Certification: By signing below, I certify that I have read and understand the terms of this approval, that I consent to the provision of the approved services under the stated conditions, and that I accept financial responsibility as described herein unless otherwise covered by my insurer.

Sign Now