Formas Clinicas

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Email
example@example.com

Introductory Information

This section is used to create a record of authorized persons in association with this client claim.
Today's Date:*

MonthDayYear
Date
Who is filling out this form?*

PatientAuthorized Representative On Patient's behalf
Relationship to Patient:*

Identification Information: Patient

Please provide all requested information pertaining to the patient in full.This ensures we have accurate and complete records to support proper care and documentation.
Patient Name:*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
Patient Phone:*
Please enter a valid phone number.
Patient Email:*
example@example.com
Patient Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Patient / Authorized Representative's Signature:*

Clear

Identification Information: Authorized Rep or Patient

Please provide the required contact information for the individual completing this form.
Who should fill out this section?
- If you are an Authorized Representative (someone other than the patient completing this form on the patient's behalf), please provide your identification information below—this is to ensure accurate and complete documentation.
- If the Patient is completing this form themselves, the section below is still required—even if the same information was already provided earlier—this is to ensure accurate and complete documentation.
Name (Person Completing this Form):*

First NameLast Name
Date of Birth (Person Completing this Form):*

MonthDayYear
Date
Phone Number (Person Completing this Form):*
Please enter a valid phone number.
Email (Person Completing this Form):*
example@example.com
Home Address (Person Completing this Form):*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Signature (Person Completing this Form):*

Clear

ASSIGNMENT OF BENEFITS

IN ACCORDANCE WITH TITLE 29 U.S.C sec. 1132(a)(1)(B)
Patient's Name: {patientName}
Patient's Date of Birth: {date}
Health Plan Member / Subscriber's Name:*

First NameLast Name
Insurance Provider:
Health Plan Member ID:*
Acknowledgment

Confirmation of Authorization by the Patient or Their Representative
I, {nameperson}, the above-named member, or authorized person signing on behalf of Patient, agree that payment for the services provided by 24-7 Medical Group, its employees, contractors and agents, are due at the time of service at the rates and charges set forth in theMedical Transport Agreement. In the event that I, or the Patient, or any other representative, trustee, executor, heir or assignee, is entitled to benefits of any type arising out of any policy of insurance or health benefit plan insuring the Patient or any other party liable to me or thePatient, those benefits are hereby irrevocably assigned to 24-7 Medical Group for the application against the charges for 24-7 Medical Group services. Except as otherwise expressly agreed in writing, I shall remain responsible for any and all charges to be paid by the insurance company or other third-party payer and /or not covered by this assignment. Full cooperation shall be provided to assist 24-7 Medical Group in collecting the charges for its services. I direct any insurers or health plans to acknowledge and act in accordance with this assignment.I hereby designate 24-7 Medical Group as my beneficiary related to all such rights and authorize24-7 Medical Group to represent me and the Patient and to act on behalf with regard to any and all rights to which the Patient and/or I have, had, may have or will be entitled to, including all appeals and, if necessary court action.I hereby authorize 24-7 Medical Group to release all medical information necessary to process any claim(s). I hereby authorize any plan administrator fiduciary, insurer, attorney, and any other person in possession of information sought by MFS, to release to 24-7 Medical Group any and all plan documents, including, the Summary Plan Description, and all legally controlling documents related to such plan, insurance policy and /or settlement information upon request from 24-7Medical Group in order to claim such benefits, reimbursement, or any applicable remedies. I authorize the use of my signature on all my insurance and/or employee health benefits claim submissions and any measures 24-7 Medical Group may require in order to obtain any plan documents, medical records, or any other information it deems necessary.I hereby convey to 24-7 Medical Group to the fullest extent permissible under the law and under any applicable insurance policies and/or employee health care plan any claim, chose in action, or other legal rights I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services received from 24-7Medical Group, its employees, contractors, and agents, and to the extent permissible under the law to claim such medical benefits, insurance reimbursement, and any applicable remedies.Further, in response to any reasonable request for cooperation, I agree to cooperate with 24-7Medical Group in any attempts by 24-7 Medical Group to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, to bring suit with 24-7 Medical Group against such insurers and/or other third-party payor in my name.Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, I request that such anti-assignment provision to be disclosed to 24-7 MedicalGroup within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and the anti-assignment provision shall be invalidated. I hereby grant any and all applicable and legal rights for 24-7 Medical Group to seek and obtain payment from any responsible third party. This assignment shall not be proscribed or limited in any manner.This assignment shall be irrevocable once 24-7 Medical Group has provided services. A photocopy of this assignment shall be as valid as the original. I have read and fully understand this assignment.
Today's Date: {todaysDate693}
Patient / Authorized Representative's Signature:

Clear

Authorization

to Discuss and Release Medical Information
I, {patientName}, hereby authorize
{nameperson} as my designated representative. I grant permission for Billing911 and Provider above to discuss my account with this person to the same extent as they would myself.

I have carefully read and understand the above information, and do herein consent its disclosure. I am awarethat information regarding my medical condition will be released to those persons named above. I understandthat the persons that I authorize to receive my protected health information are not subject to federal and stateRelease of Information privacy laws, subsequent disclosure by such persons may not be protected by those laws.

I understand that this consent is subject to revocation, in writing, at any time, unless action based on it has begun.This authorization expires one year from the above date.
Patient's Date of Birth: {date}
Today's Date: {todaysDate693}
Patient / Authorized Representative's Signature:*

Clear

HIPAA Authorization

to Use and Disclose Health Information
Patient's Name: {patientName}
Patient's Date of Birth: {date}
I. My Authorization

I, {nameperson} , hereby state that I am authorized by the above-named patient and I hereby authorize the use and disclosure of the following protected health information by 24-7 Medical Group, its employees, contractors and representatives, and by and to the following:

Such medical facilities, professionals and personnel as necessary for the care of the Patient and all related services including, without limitation, Hospital Name (Optional) Hospital, and Facility Name (Optional) Medical Center.
My Authorization (check all that apply)*

All health information of the patient(s) maintained for the above-named patient(s)All health information relating to the patient(s) as may be requested by 24-7 Medical GroupOther: H & P (History and Physical), Face Sheet, Inpatient and Outpatient medical notes and diagnostic testing.
You may disclose this health information to: 24-7 Medical Group, its employees, contractors and representatives. (Check all that apply)*

At my requestTo assess needs for a medical transportTo assist with claims reimbursement for insuranceOther
This Authorization Ends

Upon full payment to 24-7 Medical Group for its services
II. My Rights

I understand I do not have to sign this authorization form in order to obtain health care benefits (treatment, payment orenrollment).

I may revoke this authorization in writing by sending written notice to: 24-7 Medical Group c/o Billing 911 P.O. Box 55,Watsontown, PA 17777. Such notice will not apply to actions taken by the requesting person/entity prior to the date theyreceive your written request to revoke authorization.
Patient's / Representative's Printed Name: {nameperson}
Today's Date: {todaysDate693}
Patient / Authorized Representative's Signature:*

Clear

HIPPA Compliant Authorization

to Disclose PHI Pursuant to 45 CFR Parts 160 & 164 (HIPPA)

A. Facility Questions (Optional)
Release From Facility
Facility Name (Optional)
Facility Address (Optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone Number (Optional)
Please enter a valid phone number.
Facility Email (Optional)
example@example.com
Release To Facility
Facility Name (Optional)
Facility Address (Optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone Number (Optional)
Please enter a valid phone number.
Facility Email (Optional)
example@example.com

END
Patient Demographics
Patient's Name: {patientName}
Patient's Date of Birth: {date}
Patient's Address: {patientHome}
Patient's Insurance: {insuranceProvider}
Patient's Medical ID Number: {healthPlan8}
Patient's Address: {patientHome}
Patient's Phone Number: {patientPhone}
Patient's Email: {patientEmail}
Today's Date: {todaysDate693}

B. Facility Questions (Optional)
Pick-Up Facility (Optional)
Drop Off Facility (Optional)

END
Information Requested

I hereby authorize the above named provider or insurer to release the following confidential information to the person or entity name above (Initial on lines provided if required)
Select Records to Release*

Release All RecordsRelease Individual Records
Release All Records (Patient / Authorized Representative's Signature):*

Clear
Select Individual Records To Release*

Hospitalization RecordsDischarge Summary RecordsH & P RecordsMental Health Treatment RecordsSubstance Abuse Treatment RecordsHIV / AIDS / STD Results RecordsOther
Hospitalization Records (Patient / Authorized Representative's Signature):*

Clear
Discharge Summary Records (Patient / Authorized Representative's Signature):*

Clear
H & P Records (Patient / Authorized Representative's Signature):*

Clear
Mental Health Treatment Records (Patient / Authorized Representative's Signature):*

Clear
Substance Abuse Treatment Records (Patient / Authorized Representative's Signature):*

Clear
HIV / AIDS/ STD Results Records (Patient / Authorized Representative's Signature):*

Clear
Other Records (Patient / Authorized Representative's Signature):*

Clear
Consent for Release

Medical Information Release and Authorization (Optional)
I, or my authorize representative, request the disclosure of my protected health information as set forth on this form, in accordance with the HealthInsurance Portability and Accountability Act of 1996 (HIPPA). I understand that:

1) The Information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome(AIDS), human immunodeficiency virus (HIV), alcohol and drug abuse, or mental health treatment, only if I have place my initials on the appropriate items listed above.

2) I understand that signing this authorization is voluntary. My treatment or payment for my treatment is not conditioned on my authorization for disclosure.

3) I have a right to revoke this authorization at any time by writing to the health care provider listed above, except to the extent information has been released in reliance upon this authorization.

4) I understand that the information disclosed pursuant to the authorization may be re-disclosed by the recipient and no longer protected by the federal privacy regulations.

5) All items on this form have been completed by me and all of my questions have been answered.This Authorization shall be in full force and effect until Date (Optional) ; or until two (2) years from the date of execution, at which time this authorization expires.

END
Patient's / Representative's Printed Name: {nameperson}
Patient / Authorized Representative's Signature:*

Clear
Today's Date: {todaysDate693}
Relationship to Patient: {relationshipTo712}

Non-Participating (Out-of-Network)

ProviderBilling Authorization Form
To: Billing911
Clinic Name (Optional)
Patient's Name: {patientName}
Patient's Insurance: {insuranceProvider}
Billing Instructions:

The attached claim reflects our Participating (In-Network) Provider rates that DO NOT apply in thiscase. As per our Billing Agreement, please invoice this patient’s insurance provider for the medicalservices rendered consistent with the Non –Participating (Out-of –Network) Provider ChargeMaster rates we have previously provided you with. This billing authorization does not revokeBilling911’s right to negotiate on our behalf to become a Participating (In-Network) Provider.
Patient / Authorized Representative's Signature:*

Clear
Today's Date: {todaysDate693}

Patient Consent

To Release of Medical InformationAssignment of Medical Benefits and Designation of Authorized Representative Assignment of Rights to Pursue Erisa and Other Legal and Administrative Claims

Patient Consent Information (Read Only)
I, the undersigned, understand 24/7 Medical Group and/or its third-party claims manager’s Billing911, and its assign shall attempt to process all claims through my insurancecarrier/payer. I understand and agree that should my insurance carrier/payer fail to pay all monies owed to 24/7 medical Group, I shall be personally responsible for payingany remaining monies owed for the services, treatments, therapies and medications rendered or provided by the Center, or their designated representative. I understand that the costs of such services shall be determined in accordance with the publicly available billing schedule maintained by the Center and available for my review. Iacknowledge that I am not eligible for any discounting as set forth in the Center’s billing schedule.

Assignment of Benefits: I assign to 24/7 Medical Group or its designee any payment, right to payment, all medical benefits and/or insurance reimbursements, if any,otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by 24/7 Medical Group and/or their designated representative. Iauthorize 24/7 Medical Group to release any necessary medical records to ensure payment. I also authorize my plan administrator, fiduciary, insurer and/or attorney torelease to 24/7 Medical Group or its designated any and all Plan documents, summary of benefits description (SPD), insurance policy, and/or settlement information uponwritten request from 24/7 Medical Group, It’s designee and//or attorney in order to claim such medical benefits.

Designation of Authorized Representative: In addition to the Assignment of Benefits and/or Insurance Reimbursement above. I hereby appoint 24/7 Medical Group and/orBilling911 and its designee as my Authorized Representative. I also assign and convey to 24/7 Medical Group or its designee any legal or administration claim or cause ofaction arising under any group health plan, employee benefits plan, health insurance or tort fees or insurance concerning medical expenses incurred as a result of the medicalservices, treatments, therapies, and/or medication I receive from 24/7 Medical Group or their designated representative (including the right to pursue those legal oradministrative claims or cause of action.) This constitutes an express and knowing assignment or rights in accordance with ERISA Title 29 U.S.C. for breach of fiduciary claimsand other legal and/or administrative claims.

Patient Consent to Release Medical Information: I intend this assignment of Benefits and Designation of authorized Representative to convey to 24/7 Medical Group and itsdesignee, all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or medications provided by 24/7 Medical Groupor their designated representative, including the rights to any settlement, insurance, insurance or applicable legal or administrative remedies (including damages arising fromERISA or fiduciary duty claims). 24/7 Medical Group is given the right by me to: (1) obtain information regarding the claim to the same extent as I: (2) Submit evidence; (3)make statements about facts and law; (4) make any request including providing or receiving notice of any proceedings; (5) participate in any administrative and judicial actionand pursue claim so cause of action or right against the liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. 24/7 MedicalGroup or its designee, my Assignee and Designated Representative, may bring suit against any such health care benefit plan, employee benefit plan administrator or insurancecompany in my name with derivative standing at provider’s expense.

Unless revoked, this Assignment is valid for all administrative and judicial reviews under PPACA (Health Care Reform Legality, ERISA, Medicare or applicable federal and statelaws. A photocopy of this Assignment is to be considered valid, the same as the original.

I recognize that should I, or my insurance company on my behalf, fail to pay all monies owed for services provided by 24/7 Medical Group and /or its assignees may seek ajudgment against me for any and all monies owed. I hereby consent and submit jurisdiction of my home state, with respect to any monies owed for services provided by 24/7Medical Group. I accept service of process in any legal action for the recovery or monies owed for services provided by 24/7 Medical Group through Certified U>S> Mail at theaddress I have provided. I understand that 24/7 Medical Group and/or its assignee may seek to collect on any such judgment in the United States and that to the extentpermitted by law, services of process via Certification shall be valid and acceptable.

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT AND ACKNOWLEDGE I HAVE RECEIVED A COPY FOR MY RECORDS

END
Patient / Authorized Representative's Signature:*

Clear
Patient / Insured or Authorized Representative Name: {nameperson}
Today's Date: {todaysDate693}

Patient Information
Patient's Name*

First NameMiddle NameLast Name
Patient's Age*
Patient's Gender*

MaleFemale
Patient's Date of Birth: {date}
Patient's Social Security Number (Optional)
Patient's Address: {patientHome}
Patient's Phone Number: {patientPhone}
Patient's Email: {patientEmail}
Patient's Occupation (Optional)
Type of Employment*

F-TimeP-TimeStudentRetired

Patient Insurance Information
Select All Patient Insurance Options that Apply*

Primary InsuranceSecondary InsuranceTravel Insurance
Primary Insurance Information
Medical Insurance Provider*
Identification #*
Subscriber's Name*

First NameLast Name
Subscriber's Date of Birth*

MonthDayYear
Date
Subscriber's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber's Phone Number*
Please enter a valid phone number.
Secondary Insurance Information
Medical Insurance Provider*
Identification #*
Subscriber's Name*

First NameLast Name
Subscriber's Date of Birth*

MonthDayYear
Date
Subscriber's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber's Phone Number*
Please enter a valid phone number.
Travel Insurance Information
Medical Insurance Provider*
Claim #*
Subscriber's Name*

First NameLast Name
Subscriber's Date of Birth*

MonthDayYear
Date
Subscriber's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber's Phone Number*
Please enter a valid phone number.