Healthcare Sub-Certification

Healthcare Sub-Certification

Patient Information

Patient Name:

Date of Birth:   Gender:

Phone:   Email:

Relationship:   Phone:

Insurance and Subscriber Information

Policy / ID Number:   Group Number:

Subscriber Name:

Medical and Service Information

From:   To:

Sub-Certification and Attestation

By signing below, I hereby certify, under penalty of perjury and to the fullest extent permitted by applicable law, the following:

1. The information provided in this Sub-Certification is true, accurate, and complete to the best of my knowledge. I understand that knowingly providing false information may subject me to civil and criminal penalties and obligations to repay improper payments.

2. The services described above were actually rendered as indicated, were medically necessary, and were not billed to any other payer for the same service period.

3. I authorize the release of medical and billing records related to the services described herein to the payer(s), authorized agents, and oversight bodies for the purpose of payment, audit, investigation, or quality assurance. This authorization includes records necessary to verify the accuracy of claims and eligibility for benefits.

4. I assign to the payer(s) any rights to subrogation or recovery against third parties for payments made on my behalf for these services and will cooperate in the recovery of such payments if requested.

5. I certify that the rendering provider(s) and any subcontracting entities involved in my care were properly licensed, credentialed, and not excluded from participation in federal or state healthcare programs at the time services were provided.

HIPAA Acknowledgment and Authorization Expiration

I acknowledge receipt of the provider's Notice of Privacy Practices and understand my rights regarding the use and disclosure of my protected health information. I authorize the use and disclosure described in this document for the purposes stated above.

This authorization expires on: . I understand I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization.

Additional Declarations

Check all that apply:

I affirm that the services were medically necessary as documented by the provider.

I affirm these services have not been and will not be billed to another payer for the same dates of service.

I consent to assignment of benefits and subrogation rights to the payer as described above.

Provider / Facility Information (if applicable)

Provider NPI / Tax ID:

Signature and Certification

Relationship to patient (if signing on patient's behalf): Self    Parent/Guardian    Power of Attorney    Other:

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