Provident Claims Services, Inc.

PO Box 38295

Pittsburgh, PA 15238-8295

Toll-Free: 800.478.1752 | Fax: 412.963.0148

Email: claims@providentclaims.com

Website: providentclaims.com

 

Business Hours: 8:30 AM to 5 PM

Please note, this document could take up to 15+ minutes to complete. If you wish to start filling it out now, you can always press "Save & Continue Later" at the bottom of this form to complete and submit at a later time. 

Review our Important Notice Regarding Fraud before continuing:

THIS FORM IS ONLY ACCEPTABLE FOR USE WHEN APPLYING FOR MENTAL STRESS MANAGEMENT BENEFITS

I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE AND COMPLETE ACCORDING TO THE BEST OF MY KNOWLEDGE AND BELIEF.

I hereby authorize any physician, hospital, insurer, governmental agency, other organization or person having any records, data or other information concerning me to furnish such records, data or information as may be requested by Provident or its duly authorized representative. I understand that in executing this authorization I waive the right for such information to be privileged. A copy of this authorization shall be considered as effective and valid as the original.

THE AUTHORIZATION INCLUDED WITH THIS FORM MUST BE SIGNED AND RETURNED TO PROVIDENT CLAIMS SERVICES, INC.

See Important Notice Regarding Fraud in the PDF at the beginning of this form. 

Failure to complete this form in its entirety may result in a delay of processing your claim. 

Please sign and submit this authorization to Provident Claims Services, Inc. (PCS). You are entitled to receive a copy of this authorization. This authorization is designed to comply with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

Authorization to Disclose Psychotherapy Notes

I authorize ______________________________________ (print name of health care provider) (“Provider”);

To disclose Psychotherapy Notes;

To the following persons: Provident for the purpose of evaluating and administering claims, includingassistance with return to work.

This authorization applies to medical records created by Provider and to any records that Provider receivedfrom any other source as long as the other source has not prohibited disclosure of those records.

“Psychotherapy Notes” means notes about me, recorded in any form, by a health care provider who is amental health professional; that document or analyze the contents of conversation during a private, group,joint or family counseling session; and, that are separate from the rest of my medical record. “PsychotherapyNotes” does not mean: medication prescription and monitoring; counseling session start and stop times; themodes and frequencies of treatment furnished; results of clinical tests; and, any summary of the followingitems: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

Information authorized for use or disclosure may include information which may indicate thepresence of a communicable or non-communicable disease.

If I do not sign this authorization or if I alter or revoke it, Provident may not be able to evaluate my claim(s),which may lead to my claim(s) being denied. I may revoke this authorization at any time by sending writtennotice to the address above. I understand that revocation will not apply to any information that is requestedprior to Provident receiving notice of revocation.

The privacy protections established by HIPAA may not apply to information disclosed under thisauthorization, but other privacy laws do apply. Information disclosed under this authorization may beredisclosed only as permitted or required by law, including state fraud reporting laws.

This authorization is valid for one (1) year from the date below, or the duration of my claim(s), whicheverperiod is shorter. A copy of this authorization is as valid as the original.

I authorize any physician, medical professional, hospital, covered entity as defined under HIPAA, insurer or other organization or person having any records, dates or information concerning the claimant to disclose when requested to do so, all information with respect to any injury, policy coverage, medical history, consultation, prescription or treatment, and copies of all hospital or medical records or all such records in their entirety to Provident Claims Services, Inc., on behalf of AXIS Insurance Company or its designated administrator. This authorization shall remain valid for a period of two years from the date signed. A photo static copy of this authorization shall be considered as effective and valid as the original. A copy of the authorization is available upon request of the company.

Parts 1 and 2 must be completed to properly identify the records to be released:

I understand that this Authorization is valid for a period of two (2) years from the date of the signature, or the duration of my claim, whichever is shorter. A photographic or electronic copy of this authorization is as valid as the original. I understand that I am entitled to receive a copy of this authorization. I understand that once this information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. I understand that I have the right to revoke this authorization at any time by sending a written request to the entity/person I authorized above to release information.

**THE USE OF AN AUTHORIZED REPRESENTATIVE IS ONLY APPLICABLE IF THE MEMBER IS UNABLE TO SIGN ON THEIR OWN BEHALF.**

As an authorized representative, I have uploaded the documentation granting this authority. Please refer to POA, Guardianship, or Estate documentation. 

Authorization Agreement (ACH Direct Deposit Only). By signing below, I (the "Receiver") authorize Provident Claims Services, Inc. (PCS) (the "Originator") to initiate Automated Clearing House (ACH) credit entries (direct deposits) to the deposit account identified below (the "Account"). This authorization is limited to the direct deposit of claim payment proceeds and any permissible correcting entries related to those deposits.

This form is to be used for PCS direct deposit of funds only.

No Liability for Bank Delays/Incorrect Information. I understand the Originator is not responsible for delays or losses caused by incorrect or incomplete information I provide, actions or errors by my financial institution, or events outside the Originator's reasonable control.

Compliance and Dispute Cooperation. Entries initiated under this authorization will comply with the Nacha Operating Rules and applicable U.S. law. I certify that I am an authorized signer or owner of the Account and authorize my financial institution to provide information needed to resolve any entry, return, or notice of change related to this authorization.

Revocation/Changes. This authorization will remain in effect until the Originator receives my written notice to change or revoke it. Any change or revocation request must be received at least five (5) banking days before the next scheduled deposit date to allow a reasonable opportunity to act.

Notice of Issues. I will promptly review my Account activity and notify PCS if a direct deposit has not been received or if an amount is incorrect. To the extent permitted by law and the Nacha Rules, claims relating to an unauthorized or erroneous entry are subject to applicable reporting timeframes.

Correction, Reversal, and Adjustments for Errors. If an entry is made in error (including an incorrect amount, duplicate entry, wrong account, or wrong effective date), I authorize the Originator to initiate a correcting entry or reversal as permitted by the Nacha Operating Rules and applicable law. The Originator will make reasonable efforts to notify me of any reversal and the reason for it as required by the Nacha Rules.

Account Verification and Receipt of Entries. I authorize the Originator and its financial institution to verify my Account information, including by initiating one or more prenotification (zero-dollar) entries or other commercially reasonable verification methods, and to deposit funds to the Account in accordance with this authorization.

Privacy and Data Use Notice. PCS will use the banking and personal information provided on this form solely for the purpose of initiating and administering ACH direct deposit transactions and for related operational, legal, and compliance purposes. Such information will be maintained and safeguarded in accordance with applicable federal and state privacy and data security laws, including the Gramm-Leach-Bliley Act (GLBA), and will not be disclosed to third parties except as necessary to process ACH transactions, comply with law, or as otherwise permitted by applicable regulations.