Healthcare Integrity Form

HEALTHCARE INTEGRITY FORM

Patient Information

Insurance Information

Medical History (brief)

Statement of Integrity and Certification

By signing below I certify that the information provided on this form is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information in connection with health services, insurance claims, or benefits may give rise to civil and criminal liability including but not limited to fines, penalties, and repayment of amounts paid on my behalf.

I acknowledge that I have a continuing obligation to notify the facility in writing of any change in insurance coverage, address, or any facts that may affect coverage or payment of services. I certify that I will not knowingly submit claims or permit claims to be submitted that misrepresent services rendered, diagnosis, or patient identity.

I certify the information above is accurate and understand the penalties for fraud, waste, or abuse.

I agree to inform the provider promptly of any changes to insurance, address, or eligibility.

Authorization to Verify Insurance and Assign Benefits

I authorize the release of any information necessary to process claims and verify coverage. I authorize payment of medical benefits to the provider for services furnished to me. This assignment includes any benefits payable for care related to the services rendered by the provider named on my account.

I authorize the provider to verify coverage and benefits with my insurer and to submit claims on my behalf.

I assign benefits and authorize payment to the provider for services rendered as described above.

Authorization to Release Protected Health Information

I authorize the disclosure of my protected health information (PHI) to insurers, third-party payors, and their agents as necessary for adjudication of claims and verification of benefits. This authorization includes history, diagnoses, treatment records, and billing information relevant to claims submission and investigation of suspected fraud or billing irregularities.

I understand this authorization is voluntary but required for processing insurance claims. I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

Financial Responsibility and Fraud Reporting

I understand that I am financially responsible for any charges not paid by my insurer, including deductibles, copayments, coinsurance, and services not covered. I authorize the provider to seek reimbursement from me if payment is denied due to incorrect or incomplete information I provided.

If I become aware of suspected fraud, waste, or abuse involving my care or claims, I will report such concerns to the provider's compliance office or other designated reporting channels. I understand that laws provide protections for good faith reports of suspected wrongdoing.

I acknowledge my financial responsibility for unpaid balances and agree to cooperate with billing inquiries and insurance follow-up.

I acknowledge the obligation to report known or suspected fraud, waste, or abuse.

Additional Information

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