Healthcare DX Expansion Form

HEALTHCARE DX EXPANSION FORM

Purpose: This form documents the request to add, expand, or clarify one or more diagnoses (DX) in the patient's active medical record for clinical, administrative, billing, and continuity-of-care purposes. Completion of this form authorizes review of relevant medical records and the inclusion of the expanded diagnosis(es) where clinically justified.

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance & Coverage

Clinical & Medical History

Requested Diagnostic Expansion

Requested Diagnosis 1 (ICD-10 or description):

Date of Onset (if known):    Supporting Clinician:

Requested Diagnosis 2 (optional):

Date of Onset (if known):    Supporting Clinician:

Supporting Documentation

Check all supporting items attached or available for review:

Clinical notes / progress notes

Laboratory results

Imaging reports

Other (specify below)

Administrative & Legal Acknowledgments

By signing this form the patient or legally authorized representative: (a) authorizes clinicians and health records staff to add or expand the diagnosis(es) listed above in the medical record where clinically supported; (b) authorizes release and review of relevant medical records from other providers to corroborate diagnostic findings when necessary; and (c) acknowledges that inclusion of expanded diagnosis(es) may affect coding, claims submission, utilization management, and coverage determinations by payers.

The provider certifying the clinical rationale shall ensure that the diagnosis expansion is supported by contemporaneous clinical documentation consistent with prevailing clinical standards. Any intentional falsification of clinical information to secure coverage or payment is prohibited and may be subject to administrative, civil, or criminal sanctions.

Right to Withdraw: The patient or legal representative may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. Revocation should be submitted to the health records department.

Confidentiality & HIPAA: The information disclosed as part of this request is protected health information. It will be used and disclosed only as necessary to accomplish the diagnostic expansion and related administrative actions, except as required by law. The patient acknowledges receipt of the provider's privacy practices.

Patient Acknowledgment: I acknowledge that the clinical information provided on this form is accurate to the best of my knowledge and that I have had the opportunity to ask questions regarding this diagnostic expansion.

Consent to Contact Payer for Verification: I authorize the provider to contact my payer to verify coverage or obtain pre-authorization related to the expanded diagnosis(es).

Requesting Clinician / Office Use

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