Healthcare Insurance Request

HEALTHCARE INSURANCE REQUEST

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance / Subscriber Information

Insurance Company:

Request Details

Type of Request (select all that apply):

Eligibility / Benefits Verification    Prior Authorization / Precertification    Predetermination of Benefits

Claim Status / Appeal    Referral Request    Other:

Urgency: Routine    Urgent    Emergent

Medical Information

Is the condition related to:   Work    Auto accident    Liability / Other

Authorization and Certification

By signing below, I authorize the release of medical information necessary to process this request and to the insurer, its agents, and designated representatives for the purpose of determining eligibility, benefits, claims adjudication, or prior authorization. I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that this authorization includes relevant medical records, diagnoses, treatment plans, and billing records related to the requested service.

I hereby assign benefits payable for services described herein to the provider listed above and authorize direct payment to that provider where permitted. I understand that I remain financially responsible for services not covered by insurance or for amounts not paid by the insurer. This authorization is valid until the expiration date below or until revoked in writing. A copy of this authorization is considered as valid as the original.

HIPAA Acknowledgment: I acknowledge that I have read and understand that protected health information may be used and disclosed in connection with this request as described above.

Attestation

I certify under penalty of perjury that the information provided in this Healthcare Insurance Request is true and correct to the best of my knowledge. I understand that willful misrepresentation may result in denial of benefits and may subject me to civil or criminal liability under applicable law.

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