Healthcare Service Provider Request

Healthcare Service Provider Request

Requesting Party Information

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Insurance Information

Current Clinical Information

Requested Provider & Service Details

Specialty:    Preferred Location:

Service Requested (brief):

Urgency: Routine Urgent Emergent

Attachments & Additional Materials

Include copies of supporting records (select all that apply):
Lab reports Imaging (X-ray, MRI, CT) Operative notes Progress notes Other

Authorization to Release Information & Billing

I authorize the release of my protected health information, including medical records and billing information, to:

This authorization is valid for the purpose of coordinating care, scheduling, claims processing, and related administrative functions. This authorization expires on:

I understand that I may revoke this authorization at any time by submitting a written revocation, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected under federal privacy regulations.

Financial responsibility: I acknowledge that I am responsible for charges not covered by insurance, and that submission of this request does not guarantee coverage or payment by my insurer.
I acknowledge financial responsibility.

HIPAA & Privacy: I acknowledge I have been informed of the facility's privacy practices and consent to release necessary information for care and claims processing.

Certification

I certify that the information provided on this request is accurate to the best of my knowledge. I request and authorize the placement of this service request and related disclosures as necessary to facilitate my care. I understand that falsification or omission of material facts may result in denial of services.

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