Healthcare Initial Approval Packet

HEALTHCARE INITIAL APPROVAL PACKET

Patient Information

Date of Birth:    Gender:

Primary Phone:    Secondary Phone:

Insurance Information

Policy/ID Number:    Group Number:

Medical History & Current Status

Primary Care Physician:

Requested Service / Treatment

Primary Diagnosis (ICD code / description):

CPT / Procedure Code:    Requested Start Date:

Clinical Justification & Supporting Information

Supporting documentation attached (check all that apply):

Labs / Pathology    Imaging (reports)    Clinical Notes    Other:

Authorization to Release Medical Information

I authorize all treating providers and facilities to disclose my protected health information (PHI) relating to the condition and treatment for which approval is sought to the payer, utilization review entity, and providers involved in care coordination. This authorization includes, but is not limited to, history and physicals, progress notes, lab and imaging reports, operative reports, and billing records to the extent necessary to process this approval request. I understand that the information released under this authorization may be re-disclosed by the recipient and may no longer be protected by privacy laws.

Authorization expires on: . I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization.

HIPAA Privacy Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices and understand that the healthcare provider and health plan may use and disclose my PHI for treatment, payment, and healthcare operations in accordance with the Notice. By signing below I consent to the release of information necessary to obtain payment and approvals for health care services.

I understand that I have the right to request restrictions on certain uses and disclosures of my PHI and the right to receive a copy of the Notice of Privacy Practices upon request.

Certification and Attestation

By signing this packet I certify that the information provided is true, accurate, and complete to the best of my knowledge. I understand that deliberate falsification or omission of information may result in denial of coverage or other administrative action. I authorize release of medical and billing information as necessary to process this approval request and understand that coverage decisions rest with the payer based on submitted clinical information.

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