Healthcare TPA Form

HEALTHCARE TPA AUTHORIZATION AND ASSIGNMENT FORM

TPA and Plan Identification

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance & Subscriber Information

Provider / Treatment Information

Dates of Service From: To:

Authorization to Release Protected Health Information (PHI)

I authorize the release of my protected health information, records, and billing information to the named Third-Party Administrator and its authorized agents for the purposes described in this form. This authorization includes disclosure of information necessary for claims adjudication, payment, utilization review, care coordination, quality assurance, and appeals.

I understand that the information to be disclosed may include but is not limited to: medical histories, diagnostic tests, treatment records, billing and payment records, and other information relevant to the treatment and payment of services described above.

Claims administration & payment    Utilization review & quality assurance    Care coordination & case management    Legal, audit, or compliance review

Sensitive Information

Certain categories of information are particularly sensitive and will not be released without explicit authorization. Please indicate any categories you specifically authorize to be released:

Mental health records (excluding psychotherapy notes)    Substance use disorder treatment records    HIV/AIDS related records    Genetic testing information

Note: Psychotherapy notes, if present, require a separate specific authorization and will not be released under this general authorization unless expressly indicated in writing with a separate attachment.

Assignment of Benefits and Payment Authorization

Assignment: I authorize payment of insurance benefits and any plan payments to the provider and/or the named TPA for services furnished to me. I assign to the provider and to the TPA the right to collect directly from my insurer or plan any sums payable for services rendered on my behalf.

Financial Responsibility: I understand that I remain financially responsible for any deductible, coinsurance, copayment, or other charges not covered by my insurer or plan. I agree to cooperate with the TPA and my insurer in coordination of benefits and claims processing, including timely submission of documentation.

Expiration, Revocation, and Redisclosure

Revocation: I understand that I may revoke this authorization at any time by providing a written notice to the TPA. Revocation will not affect actions taken in reliance on this authorization prior to receipt of the revocation.

Redisclosure: I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy law. However, redisclosure of certain sensitive information may be restricted by applicable state or federal law.

HIPAA Privacy Acknowledgment & Certifications

By signing below I acknowledge that I have read and understand this authorization. I certify that the information I have provided in this form is true and correct to the best of my knowledge. I understand that a photocopy or electronic copy of this authorization shall be as valid as the original.

I acknowledge that I have been given the opportunity to review the plan's privacy practices and understand my rights under applicable privacy laws, including the right to inspect and obtain a copy of my medical records as provided by law.

I acknowledge that I have been provided an opportunity to receive and review the privacy practices of the plan or provider.

Medical History (Summary)

Legal Notices

False statements made in this form may be subject to penalties under applicable law. This authorization is voluntary, but necessary for the TPA and providers to process claims, coordinate benefits, and obtain payment for services. Refusal to sign may result in denial of payment from the plan or insurer.

I hereby release the provider and the TPA from any legal responsibility or liability for disclosures made pursuant to this authorization to the extent permitted by applicable law.

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