Healthcare Coding Waiver

HEALTHCARE CODING WAIVER

Purpose: This Healthcare Coding Waiver documents the patient or authorized representative's informed acknowledgement and limited waiver regarding the assignment and potential revision of medical procedure and diagnosis codes (CPT, HCPCS, ICD) for purposes of medical record coding, billing, claims processing, and related audits. The waiver authorizes release of the minimum necessary health information for coding and billing and specifies limited rights and responsibilities as set forth below.

Patient Information

Insurance / Payer Information

Clinical / Service Details

Waiver and Authorization

I, the undersigned patient or legally authorized representative, acknowledge that clinical documentation will be reviewed by qualified coding professionals and that procedure and diagnosis codes assigned may be selected or revised after initial entry to accurately reflect the clinical services rendered, the level of care provided, and applicable coding rules. I understand that coding decisions are based on clinical documentation, coding guidelines, payer policies, and professional coder review.

By signing below I expressly authorize the release of my medical records and the minimum necessary protected health information to health information management personnel, coding specialists, billing agents, and payers for the purpose of coding, claim submission, payment, audit, and appeals. I understand this waiver is limited to coding and billing activities and does not authorize release of records beyond those purposes described herein.

I acknowledge that coding changes may affect insurance coverage determinations and patient financial responsibility. I accept that I remain responsible for charges not paid by my insurer, including copayments, deductibles, and non-covered services, except as otherwise determined by contract or law. I further acknowledge that a coding revision does not constitute new treatment consent nor alter the medical care I received.

I waive the requirement for prior written notice of coding edits made solely for billing accuracy and compliance, so long as such edits are limited to assignment, correction or clarification of codes and are documented in the medical record. This waiver does not waive my right to timely notice of adverse actions unrelated to coding (for example, collections or legal proceedings), nor does it waive any statutory patient protections.

Revocation: This authorization may be revoked in writing to the health information management office, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures previously made in reliance on this authorization. Expiration: This waiver and authorization expires on unless an earlier date or event is specified here:

Authorizations and Acknowledgments (select as applicable)

I authorize release of my medical information for coding, billing, and claim adjudication as described above.

I acknowledge that coding changes may affect payer reimbursement and accept potential financial responsibility for uncovered charges resulting from legitimate coding revisions.

I consent to be contacted regarding coding or billing questions by phone, email, or mail at the contact information provided above.

HIPAA Acknowledgment

I have received or been offered a copy of the facility's Notice of Privacy Practices. I understand that my protected health information will be used and disclosed for coding, billing, and claims management consistent with applicable law and standard privacy practices.

I acknowledge receipt of the Notice of Privacy Practices or decline to take a copy (declination recorded by staff).

Medical History (Relevant to Coding)

Certifications

By signing below I certify that I am the patient identified in this document or that I am authorized to sign on behalf of the patient. I further certify that I have read this Healthcare Coding Waiver, that it has been explained to me, and that I understand its contents. I understand that signing this form is voluntary but that refusal may limit the ability of the provider to process claims accurately or to provide complete coding information to payers.

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