Insurance Service Authorization

INSURANCE SERVICE AUTHORIZATION

I authorize the release and/or disclosure of insurance and health-related information as necessary to facilitate services, treatment, claims adjudication, reimbursement and coordination of benefits. This authorization applies to the persons and organizations listed below and to the records described in this document.

Applicant / Insured Information

Policy Details

Policy Type: Health Dental Vision Disability Other

Provider / Service Information

Services Authorized

Medical evaluation and treatment
Diagnostic testing (labs, imaging)
Prescription drugs and pharmacy claims
Physical, occupational, or speech therapy
Durable medical equipment and supplies
Mental health services (note special restrictions apply)
Billing, claims submission and benefit coordination
Other (describe)

Release of Information and Authorization

I hereby authorize any physician, medical practitioner, hospital, clinic, laboratory, pharmacy, insurer, employer, or other entity holding my health, treatment or billing records to release to the named provider, my insurer, their agents, and third party payors those records necessary to process claims, provide services, and coordinate benefits. This authorization specifically includes release of billing records, claim files, itemized statements, diagnostic reports and treatment notes unless expressly excluded below.

Special categories of information (if applicable) such as substance abuse treatment records, HIV/AIDS testing and treatment records, and genetic testing results require special authorization under applicable law. By initialing below, I expressly authorize release of these categories when checked:

This authorization authorizes disclosure to the extent reasonably necessary. I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by federal privacy law. I understand that I may revoke this authorization at any time by submitting a written notice to the provider identified above; however, such revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Assignment of Benefits and Payment Authorization

I assign and authorize payment of benefits directly to the provider for services furnished under this authorization to the extent permitted by my policy. I understand I remain financially responsible for charges not covered by insurance including co-payments, co-insurance and deductibles. I authorize the provider to submit claims and receive payment on my behalf for services rendered pursuant to this authorization.

Exclusions and Limitations

This authorization does not authorize the release of psychotherapy notes unless explicitly stated. Release of information does not guarantee payment of claims or that services are covered under the policy. The provider and insurer retain the right to deny coverage or require additional documentation. Records prepared in anticipation of litigation are excluded from this authorization unless specifically requested and approved.

Documentation Checklist

Requested documentation to be released (check all that apply):

Complete medical records
Itemized bills and claims
Radiology images and reports
Laboratory test results
Photographs of injuries/property
Relevant employment records
Other documentation (describe)

Acknowledgement and Certification

By signing below I certify that I am the individual named above or the authorized representative of the individual. I certify that the information provided on this authorization is true and correct to the best of my knowledge. I understand that knowingly making a false statement or misrepresentation in connection with this authorization may constitute fraud and could result in civil or criminal penalties under applicable law.

I understand that a photocopy or electronic copy of this authorization is as valid as the original. I acknowledge receipt of a copy of this document upon my request.

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