Healthcare NonTravel Assignment Package

HEALTHCARE NONTRAVEL ASSIGNMENT PACKAGE

Patient Name:    Date of Birth:    Gender:

Patient Information

Insurance Information

Medical History

Non-Travel Services Consent and Description

I authorize the provision of non-travel healthcare services (services provided at the patient's residence or local facility and not involving travel by the provider for relocation) as described below. I understand that non-travel services may include, as applicable, nursing assessments, medication administration, wound care, therapy services, durable medical equipment setup, and case management. Services provided shall be reasonable and necessary for my care.

Risks and benefits: I understand that all medical interventions carry potential risks and benefits. The benefits of non-travel services may include stabilization of condition, prevention of complications, improved symptom management and enhanced functional ability. Risks may include but are not limited to allergic reaction, infection, worsening of symptoms, or other unforeseen complications. I have the right to ask questions and to withdraw consent at any time, subject to reasonable notice and applicable clinical considerations.

I consent to the non-travel services described above and authorize the provider to administer care consistent with my clinical needs.

Assignment of Benefits; Financial Responsibility

Assignment of Benefits: I hereby assign and authorize payment of all medical benefits and insurance proceeds, including Medicare, Medicaid, or private insurance, otherwise payable to me for services rendered by the provider, directly to the provider to the extent permitted by law. I also authorize the release of medical information necessary to process claims and to obtain payment.

Financial Responsibility: I understand that I am financially responsible for any portion of charges not paid by insurance, including but not limited to co-payments, deductibles, coinsurance, non-covered services, and charges resulting from incorrect insurance information. If my insurer denies payment, I agree to cooperate in appeals and to pay any outstanding balance as required by the provider's billing policy.

I authorize assignment of benefits to the provider and acknowledge financial responsibility as stated above.

Authorization to Release Protected Health Information (HIPAA Authorization)

I authorize the release, use and disclosure of my protected health information by the provider and its agents for the purposes of billing, claims processing, payment, quality assurance, and continuity of care related to the non-travel services described herein. Information to be disclosed may include medical records, clinical notes, diagnosis and treatment information, and related billing records.

Purpose: The information disclosed may be used for claims adjudication, payment, utilization review, care coordination and related administrative purposes. I understand that this authorization is voluntary but that refusal to sign may result in denial of assignment of benefits or delay in claims processing, but will not condition the provision of emergency treatment.

Redisclosure: I understand that protected health information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

Revocation: I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance upon this authorization. Written revocation must be submitted to the provider's privacy contact.

I acknowledge receipt of the Notice of Privacy Practices and understand my rights regarding protected health information.

Certification and Acknowledgment

By signing below I certify that I am the patient or am authorized to sign on behalf of the patient as the patient's legal guardian, health care power of attorney, or other lawful representative. I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize the provider to submit claims for services rendered and to receive payment directly from insurers, and I accept financial responsibility as described above.

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