Healthcare Recertification Application

Healthcare Recertification Application

Applicant Information

Full legal name:

Date of birth:    Gender:

Emergency Contact

Insurance and Coverage

Medical History and Current Status

Functional and Service Needs

Mobility status:

Required services (check all that apply):

Recertification Details

Recertification type: Periodic Change in condition Patient request

Requested effective date:    Anticipated expiration date:

Authorization, Certifications and Acknowledgments

I certify under penalty of perjury that the information provided on this application is true, correct and complete to the best of my knowledge. I understand that knowingly providing false information for the purpose of obtaining or continuing healthcare services may result in administrative or legal action.

Authorization to obtain and disclose records: I authorize any treating healthcare provider, facility, insurer, or payer to disclose medical records, treatment history, and benefit information relevant to this recertification request to the organization processing this application and to its agents for the purpose of determining eligibility and medical necessity. This authorization includes protected health information and remains effective until the anticipated expiration date above unless earlier revoked in writing. I understand that revocation does not affect disclosures made prior to receipt of written revocation.

Financial responsibility and assignment: I authorize assignment of benefits to the provider where applicable and accept financial responsibility for services not covered by insurance or other payers. I authorize payment of benefits directly to the treating provider when allowed by my plan.

HIPAA Privacy Acknowledgment: By signing below I acknowledge that I have received and reviewed the entity's Notice of Privacy Practices and understand my rights regarding the use and disclosure of my protected health information as required by law.

This authorization will expire on:

Revocation: I understand I may revoke this authorization at any time by submitting a written notice to the organization processing this recertification application. Revocation will not apply to information already released in good faith in reliance on this authorization.

Attestation and Signature

By signing below I attest that I am the patient named in this application or the duly authorized representative of the patient. I declare under penalty of perjury that the foregoing is true and correct.

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