Healthcare Service Attestation

HEALTHCARE SERVICE ATTESTATION

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Policy Number:    Group Number:

Subscriber DOB:

Medical History

Service Details

Date of Service:    Service Location:

Performing Provider:    Title:

Attestation and Authorizations

By signing below I certify under penalty of law that the information I have provided on this attestation is true, complete, and accurate to the best of my knowledge. I attest that I personally received the services described above and that the services were provided on the stated date(s).

I acknowledge and authorize the following (check all that apply):

I received an explanation of the nature of the services, expected benefits, and material risks.

I confirmed my identity to the provider and presented valid identification.

I authorize assignment of benefits to the provider and direct payment to the provider for covered services.

I understand that I remain financially responsible for services not covered by my insurance.

HIPAA Acknowledgment & Release

I acknowledge receipt of the provider's privacy practices and authorize the provider to use and disclose my protected health information as necessary for treatment, payment, and health care operations, and to disclose records to my health plan, other treating providers, and agents involved in payment or quality review.

I consent to the uses and disclosures described above.

Authorization Expiration

This authorization will expire on:

Certifications and Penalties

I understand that knowingly making a false representation on this attestation may subject me to civil or criminal penalties under applicable law. I certify that I have not knowingly provided false or misleading information to obtain services or benefits.

I authorize the release of medical and billing information necessary to process claims and to allow for audits, reviews, or other lawful purposes related to payment and quality assurance.

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