Healthcare Memic Application

Healthcare MEMIC Application

Patient Information

Date of Birth:    Gender: Female Male Other / Prefer not to disclose

Emergency Contact

Insurance Information

Subscriber Date of Birth:    Relationship to Patient:

Assignment of Benefits: I authorize direct payment of insurance benefits to the provider for services rendered.

Medical History

Consent and Authorizations

By signing below, I authorize Healthcare MEMIC and its delegated providers to render medical treatment, diagnostic testing, and emergency care as deemed necessary by licensed practitioners. I understand that no specific procedure is guaranteed by this application; specific informed consent will be obtained for procedures that require it.

I authorize the release of my medical, billing, and insurance information to the extent necessary to process claims, coordinate care, and for quality assurance and utilization review. This authorization includes disclosure of records relating to mental health, HIV/AIDS status, substance use, and other protected health information except where prohibited by law.

I understand that I may 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 in writing to the provider. This authorization will expire on: unless otherwise specified here:

Assignment of Benefits and Financial Responsibility: I assign benefits payable for services to the provider and accept financial responsibility for charges not covered by insurance. I certify that the information provided on this application is true and correct to the best of my knowledge. I understand that falsifying this application may result in denial of coverage, claim rescission, or other remedies available to the provider.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices and understand my rights regarding protected health information (PHI), including the right to inspect and request amendment of my records, to request restrictions, and to request confidential communications. I understand that the provider may contact me by phone or mail at the contact information provided unless I request alternative communications below.

Alternative contact instructions or restrictions (if any):

I acknowledge and agree: I have received the Notice of Privacy Practices and authorize use and disclosure of my PHI as described above.

Certifications and Warnings

Certification: I certify under penalty of perjury that the foregoing information is complete and accurate. I understand that submission of false information may be grounds for refusal of services, termination of coverage, or pursuit of legal remedies.

Consent to Release: I authorize Healthcare MEMIC to obtain any records necessary to process claims or evaluate eligibility, and to provide copies of medical records to third parties for billing, payment, or treatment coordination when permitted by law.

Limits of Authorization: This application does not guarantee coverage, benefits, or payment. Coverage and benefits are subject to the terms of the applicable insurance contract, benefit plan, and applicable laws and regulations.

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