Healthcare Benefits Coordination Form

HEALTHCARE BENEFITS COORDINATION FORM

Patient Information

Insurance Information

Medical History (for benefits coordination)

Benefits Coordination Authorization

I authorize the health care provider and its administrative agents to obtain, use and disclose my protected health information and other information necessary to determine benefits, eligibility, and payment for services. This includes contacting my health plan(s), employer-sponsored plans, third‑party administrators, automobile insurers, and other potential payers for the purpose of verifying coverage, coordinating benefits, filing claims, appealing claim denials, and collecting payment.

Authorized recipients may include: billing departments, utilization review, case management, collection agents, and outside legal counsel as necessary to resolve payment disputes. I understand that information disclosed may include medical records, billing records, and other health information relevant to the claim.

Primary insurer
Secondary insurer
Third-party administrator
Employer/workers' compensation carrier
Other payers or agents as necessary

Assignment of Benefits and Payment

I assign to the health care provider all rights and benefits payable under any policy of insurance or by any third-party payer with respect to services rendered. I direct payment of benefits to the provider to the extent of charges for services furnished. I understand that I am financially responsible for any charges not paid by insurance or other payers.

I authorize direct payment of third-party benefits to the provider to the extent of services rendered.

Release of Information & HIPAA Authorization

I authorize the release of the medical and billing information described above in order to process claims and coordinate benefits. I understand that this authorization permits disclosure of my protected health information (PHI) for the specified purposes. I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by privacy laws.

I understand that I may revoke this authorization at any time by submitting a written revocation to the provider, except to the extent the provider or other recipient has acted in reliance on this authorization. Revocation will not affect disclosures made prior to the receipt of the revocation.

Filing and adjudication of claims
Payment collection and benefit recovery
Pursuit of appeals, grievances, or subrogation
Other:

Coordination Details and Limitations

The provider is authorized to: (1) contact payers for benefit verification and claim status; (2) request and receive copies of medical records and billing information; (3) submit claims and supporting documentation; and (4) appeal adverse benefit determinations on my behalf. This authorization does not authorize disclosure for marketing purposes.

Certifications and Acknowledgments

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that intentionally providing false information to obtain payment may subject me to civil or criminal penalties under applicable law.

I acknowledge that my consent is voluntary and that I may refuse to sign this authorization. Refusal to sign will not affect my ability to obtain treatment, but may affect payment for services from third parties. I further acknowledge receipt of the provider's privacy practices and understand my rights regarding protected health information.

If no date is provided, this authorization will expire one year from the date of signature or as otherwise permitted by law.

Representative or Guardian (if signing on behalf of patient)

Notice and Important Information

This form authorizes release and use of protected health information for the purposes described. It does not authorize release of psychotherapy notes except where specifically indicated. The provider may condition treatment, payment, enrollment, or eligibility for benefits on this authorization only where permitted by law and where the information sought is necessary for the stated purpose.

If you have questions regarding this form or your rights under applicable privacy laws, please contact the provider's privacy officer. Your signature below constitutes a clear and conspicuous authorization to proceed as described.

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