Healthcare Downstream Attestation

HEALTHCARE DOWNSTREAM ATTESTATION

This Healthcare Downstream Attestation documents the authorization and attestation by the Patient identified below relating to downstream entities, their access to patient information, and obligations to comply with applicable statutes, regulations and contractual requirements, including privacy and billing integrity obligations. Patient Name:

Patient Information

Insurance and Medical Summary

Downstream Entity Information

Subcontractor Business Associate Vendor Other:

Attestation and Authorizations

By signing below, I, the Patient identified above, hereby authorize the Downstream Entity named in this form to access my protected health information and to perform services as authorized by my treating provider, subject to the terms below. I attest as follows:

1. Compliance: The Downstream Entity will comply with all applicable federal and state laws, including privacy and security obligations under applicable health information privacy laws, and will maintain administrative, technical and physical safeguards appropriate to protect my protected health information.
2. No Exclusion: The Downstream Entity and its principals are not excluded, debarred, suspended, or otherwise ineligible to participate in federal health care programs. I understand this attestation may be relied upon by my provider and payers.
3. Billing Integrity: All billing or claims submissions prepared or transmitted by the Downstream Entity on my behalf will be accurate, complete, and in compliance with applicable billing rules. Downstream Entity must notify the provider of any errors, duplications, or overpayments and must cooperate with restitution and audits.
4. Subcontracting: The Downstream Entity will ensure that any subcontractors or agents with access to my information are bound by written agreements imposing the same obligations described herein.
5. Audit and Access: I acknowledge that my provider and authorized auditors may access records held by the Downstream Entity to verify compliance; the Downstream Entity will provide timely access and cooperation.
6. Notification: The Downstream Entity will promptly notify my provider and me of any breach or unauthorized disclosure involving my information, or any material change in the entity's ability to perform the attested obligations.
7. Record Retention: Records related to services provided and claims submitted will be retained for a period required by law and contractual obligation and made available upon request to authorized parties.

Effective Date:    Expiration Date (if any):

Revocation: I understand that I may revoke this authorization at any time by providing written notice to my provider; revocation will not affect disclosures already made in reliance on this authorization prior to receipt of revocation.

Release and use of medical records for treatment purposes
Authorization to prepare and submit billing/claims on my behalf
Communication regarding appointment scheduling and care coordination

HIPAA / Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the provider's Notice of Privacy Practices that describes how my health information may be used and disclosed. I understand that the Downstream Entity is required to safeguard my protected health information in accordance with applicable privacy and security requirements.

Certifications and Signature

By signing below I certify, under penalty of perjury and to the best of my knowledge, that the information provided on this Attestation is true and correct, that I authorize the disclosures and attestations made herein, and that I understand the consequences of knowingly providing false information.

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