Healthcare Consultancy Service Request

HEALTHCARE CONSULTANCY SERVICE REQUEST

Client Name:

Request Summary

Date of Request:

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Insurance Information

Policy/ID Number:    Group Number:

Medical History & Current Status

Services Requested / Logistics

Telehealth consultation    On-site review    Record review only

Desired start date:    Urgency level:

Attachments / Records Authorization

Check requested attachments to be provided to consultant:

Clinical notes    Imaging studies (films/CDs)    Laboratory results    Other (specify below)

Authorization & Consent

By signing below, I authorize the release and disclosure of my protected health information and relevant medical records to the healthcare consultancy firm and its designated consultants for the sole purpose of performing the requested consultation services. This authorization includes disclosure of diagnostic information, clinical notes, imaging, laboratory results, and other items necessary for evaluation.

I understand that the consultancy will use reasonable administrative and technical safeguards to protect my information but that absolute confidentiality cannot be guaranteed. I acknowledge that opinions and recommendations provided by consultants are advisory; the treating clinician retains responsibility for final patient care decisions.

I understand that I may revoke this authorization at any time by delivering written notice to the requesting client unless the consultancy has already acted in reliance on this authorization. Revocation will not affect disclosures already made pursuant to this authorization. This authorization will expire on: .

Estimated fee arrangement:    Estimated amount: $

I authorize billing to:

I acknowledge that I am responsible for any portion of fees not covered by insurance, and that the consultancy may charge reasonable costs for records retrieval and duplication.

Privacy Acknowledgment

I acknowledge that I have been informed of my rights regarding the use and disclosure of my protected health information as described in this document. I understand that the consultancy will use and disclose my information only as necessary to provide the requested services and as permitted by law.

Acknowledged: I acknowledge receipt of this authorization and privacy acknowledgment

Administrative Use Only

Date Received:    Priority Code:

Sign Now