Healthcare Plan Review

HEALTHCARE PLAN REVIEW

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Phone:    Relationship:

Insurance Information

Policy Number:    Group Number:

Subscriber DOB:    Effective Date:    Policy Expiration:

Medical History & Current Care

Plan Review Details

Review Date:    Reviewer:    Title:

Out-of-Pocket Maximum:    Deductible Amount:    Co-insurance:

Prior Authorization Required:    If yes, details:

Network Status: In-network    Out-of-network

Recommendations & Next Steps

Action Items (select all that apply):

Initiate prior authorization

Refer to specialist

Schedule follow-up appointment

Patient to contact insurer for benefits clarification

Authorization for Release / Coordination Expires:

Acknowledgment & Certifications

By signing below, I certify that the information contained in this Healthcare Plan Review is complete and accurate to the best of my knowledge. I acknowledge that I have reviewed the plan benefits, limitations, prior authorization requirements, and any cost-sharing obligations discussed above. I understand that coverage determinations are subject to the terms of the insurance policy and may be changed by the insurer. I acknowledge my right to pursue internal appeals and external review under applicable plan rules and regulatory rights.

I authorize the release and coordination of necessary plan information to members of my health care team for purposes of treatment, payment, and care coordination. I understand that this authorization expires on the date noted above or upon revocation in writing, whichever occurs first, except to the extent action has already been taken in reliance on this authorization.

HIPAA Privacy Acknowledgment: I acknowledge receipt of the organization's privacy practices and understand how my protected health information may be used and disclosed for the purposes described above.

Consent to Share Plan Information with Authorized Representative: I consent to the disclosure of plan and benefit information to the individual named below who is authorized to act on my behalf.

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