Healthcare Insurance Options

HEALTHCARE INSURANCE OPTIONS

This form records the patient's selection among available health insurance arrangements, documents acknowledgement of financial and privacy terms related to insurance billing, and provides an authorization for release of information necessary to process claims. Completion of this form does not guarantee coverage; final eligibility and benefits are determined by the insurer. Patient selection below authorizes the provider to bill selected insurance and to act on behalf of the patient for claims processing as described herein.

Patient Information

Date of Birth:

Current Insurance Information

Available Insurance Options — Selection

Please indicate the coverage option you wish the provider to bill on your behalf. Selecting an option below authorizes the provider to submit claims and to obtain necessary information from your insurer for claim adjudication.

Primary commercial insurance (bill subscriber's listed insurer; patient responsible for copays, coinsurance, deductibles and non-covered services)

Secondary insurance (bill both primary and secondary carriers as applicable; patient remains responsible for any uncovered balances)

Government-sponsored program (Medicaid/State plan) — coverage is subject to program rules and prior authorization requirements

Medicare (Part A/B/Advantage) — patient acknowledges responsibility for Part B coinsurance and services not covered by Medicare

Self-pay / Decline insurance billing (patient accepts full financial responsibility at time of service)

Effective:

Acknowledgement of Financial Responsibility

By selecting an insurance option and signing below, the patient or authorized representative acknowledges and agrees to the following substantive terms:

1. Assignment of Benefits: I assign to the provider the right to bill and receive insurance payments for services rendered. I authorize my insurer to remit payment directly to the provider to the extent permitted by my plan.
2. Patient Financial Responsibility: I am responsible for all copayments, coinsurance, deductibles, and charges for services not covered or denied by my insurer. I remain liable for any balance after insurer payment.
3. Preauthorization and Medical Necessity: Some services may require prior authorization. If services are denied as not medically necessary or due to lack of authorization, I remain financially responsible.
4. Non-Covered Services: The provider will attempt to notify me of known non-covered services; however, ultimate responsibility for coverage determination rests with my insurer and me.

I acknowledge and accept the financial responsibility terms above.

Release and Authorization for Insurance Claims

I authorize the provider to use and disclose my protected health information to my insurance carrier(s) and their agents as necessary to process claims, obtain payment, and coordinate benefits. This release includes diagnosis, treatment dates, and other information relevant to the claim. I understand that I may revoke this authorization in writing, except to the extent that actions have already been taken based on this authorization.

This authorization will expire on:

HIPAA Privacy Acknowledgement

I acknowledge that I have been provided with or offered the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I can access this information. I understand that the provider will use my health information for treatment, payment, and healthcare operations and that additional disclosures will be made only as permitted by law or with my authorization.

I acknowledge receipt of the Notice of Privacy Practices or that it was made available to me.

Additional Instructions / Comments

Certification and Signature

By signing below I certify that the information provided is true and correct to the best of my knowledge. I authorize the release of information and assignment of benefits as indicated above. I understand my financial responsibilities and that selection of an insurance option does not guarantee payment by my insurer.

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