Healthcare Panel Of Doctors

HEALTHCARE PANEL OF DOCTORS

Patient Information

Insurance Information

Medical History (Summary)

Designation of Healthcare Panel

By completing this form the Patient designates the following physicians and practitioners as the authorized panel to provide medical care, consultations and related services for the Patient while this designation is in effect. This designation authorizes the exchange of medical records and billing information between the listed providers and the Patient's insurer to the extent necessary for treatment, payment and health care operations.

Effective Date:   Expiration Date:

Panel of Physicians

List the primary clinicians included in the panel. Attach additional sheets if necessary.

If additional providers are designated, attach a supplemental list signed by the Patient and initialed on each page. The facility maintains sole responsibility for verifying provider credentials; inclusion on this panel does not guarantee insurance coverage for services rendered.

Authorization and Consent

I, the undersigned Patient, authorize the physicians and practitioners named above to provide medical evaluation, treatment, and any ancillary services deemed necessary by such providers. I authorize the release of my medical information to my insurer and to other health care professionals for treatment, payment and health care operations as required for continuity of care.

I understand that designation of this panel does not waive my right to seek emergency care from non-listed providers. I understand that some services may require prior authorization or referral and that coverage is subject to the terms of my insurance policy. I agree to be responsible for charges not covered or authorized by my insurer.

This authorization is valid from the Effective Date until the Expiration Date specified above unless earlier revoked in writing. To revoke or change this panel I must submit written notice to the facility or primary administrative contact identified by the facility. Revocation does not apply to disclosures made prior to receipt of revocation.

HIPAA / Privacy Acknowledgment

By signing below I acknowledge receipt of the facility's Notice of Privacy Practices and I authorize the disclosure of my protected health information to the providers listed on this panel for purposes of treatment, payment and health care operations. I understand that I may request restrictions on certain uses and disclosures and that the facility may deny such requests under applicable law.

I further authorize my insurer to forward any payment or explanation of benefits directly to the treating providers as needed for claim adjudication. I certify that the information provided on this form is accurate to the best of my knowledge.

Accuracy Certification

I certify under penalty of law that the information I have provided on this form is true, correct and complete. I understand that falsification of information may result in termination of privileges or other administrative actions as permitted by facility policy and applicable law.

Changes and Revocation

To add, remove, or otherwise modify any provider on this panel, submit a signed written amendment to the facility. Changes become effective on the date the facility records the amendment. Revocation of this designation must be submitted in writing and will be effective upon receipt by the facility, except to the extent reliance by third parties has already occurred.

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