Healthcare Medicaid Document

HEALTHCARE MEDICAID AUTHORIZATION & CONSENT

The undersigned authorizes the disclosure of protected health information and the submission of claims, and assigns benefits for services rendered to the patient named below to the treating provider. This Authorization and Assignment is required to permit billing to Medicaid and related program payors, to allow release of information necessary for eligibility determination, and to document the patient's understanding of rights and responsibilities under applicable health care program rules.

Patient Information

Date of Birth:

Medicaid & Program Information

Medicaid Program / Managed Care Plan:

Program Effective Date:

Insurance Information (If Applicable)

Medical History & Current Care

Authorization, Assignment of Benefits & Release of Information

I hereby authorize and direct any treating health care provider, institution, or other entity furnishing services to the patient to release to Medicaid, managed care plans, their designees, and third-party payors any medical or other information necessary to determine eligibility, benefits, claim payment, or to fulfill program requirements. This includes but is not limited to records related to diagnosis, treatment, claims, and billing.

I assign to the provider all rights to payment or reimbursement from Medicaid or related program payors for services rendered. Provider is authorized to submit claims and to receive payment directly from such payors. I understand that I remain financially responsible for any portion of charges not covered or paid by Medicaid or other payors, including copayments, deductibles, or retroactive denials resulting from failure to provide accurate information.

I authorize the release of medical information to third parties for continuity of care and program administration where required. This authorization includes information about substance use disorder treatment, mental health treatment, and communicable diseases where disclosure is permitted by law for payment and program operations.

Notice of Rights, Fraud Warning & Revocation

I understand that I have the right to revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. Revocation must be submitted to the provider in writing and will not affect disclosures made before receipt of revocation.

I understand that knowingly submitting false information or claims for payment may subject me to civil or criminal penalties under applicable law, and I certify that the information provided on this form is true and accurate to the best of my knowledge.

I acknowledge that I have been offered or received a copy of the provider's Notice of Privacy Practices as required by law.

I authorize the provider to leave appointment reminders and limited health information on my voicemail or message system.

Certification

By signing below I certify that I am the patient or am authorized to act on behalf of the patient. I certify under penalty of law that the information provided on this form is true, accurate, and complete. I authorize the submission of claims and exchange of information described above and accept responsibility for charges not paid by Medicaid or other payors when such payment is not required by program rules.

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