Healthcare Qualification Document

HEALTHCARE QUALIFICATION DOCUMENT

Patient Name:    Date of Birth:

Patient Information

Male    Female    Other    Prefer not to say

Insurance Information

Medical History & Current Health Status

Program Eligibility Checklist

The undersigned indicates that the following statements are true to the best of their knowledge (check applicable):

Diagnosis documented and meets program clinical criteria for services
Referred by a licensed provider and referral is attached
Insurance benefits are active and cover program services (if applicable)
Residency/eligibility residence requirement met
Prior authorization obtained when required

Required Documentation Checklist

Please indicate which documents are attached or provided:

Proof of identity (government ID)    Insurance card copy    Provider referral or order    Recent medical records / lab results

Authorization to Obtain and Disclose Records

I authorize any healthcare provider, facility, insurer, pharmacy, or other entity to release and disclose medical, billing, and insurance information necessary to determine my eligibility, coordinate care, and process payment for services related to this application. This authorization specifically includes but is not limited to diagnoses, treatment summaries, medication lists, imaging and laboratory results, and physician notes.

I understand that information disclosed pursuant to this authorization may include sensitive health information and that such information will be used solely for eligibility determination, care coordination, quality assurance, utilization review, or billing. I further authorize the recipient to disclose this information to other parties when necessary to accomplish these purposes.

This authorization will expire on: . I understand I may revoke this authorization at any time by providing written notice, except to the extent that actions have already been taken in reliance on it.

Consent to Care and Acknowledgments

By signing below I consent to the release and exchange of the information described above and request consideration for program qualification. I certify that the information I have provided in this Healthcare Qualification Document is complete and accurate. I understand that knowingly providing false or incomplete information may result in denial of eligibility, termination of program services, and may subject me to penalties under applicable law.

I understand that qualification under this document is an administrative determination and does not itself guarantee that any particular service will be provided. Final authorization of services is subject to program policies, clinical review, funding availability, and insurer determinations where applicable.

HIPAA Privacy Acknowledgment

I acknowledge that I have been provided with the entity's Notice of Privacy Practices describing how my medical information may be used and disclosed and my rights under privacy law. I authorize the use and disclosure of my protected health information as described in this document and understand my rights to request restrictions or to receive confidential communications by alternate means or at an alternate location; such requests must be submitted in writing.

Optional Consents

I permit program staff to contact me by phone regarding eligibility and care coordination.
I permit program staff to send text messages or emails regarding appointment reminders and administrative notices.
In the event of an emergency, I consent to treatment necessary to stabilize my condition until a legally authorized representative can be contacted.

Additional Information (Provider Use)

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