Prior Authorization Consent

Consent for Prior Authorization Submission

I,  First Name   Last Name   , hereby consent and authorize Bottumuzup Health and Wellness, LLC and their office staff to submit a prior authorization request to my insurance company or other relevant parties on my behalf. I understand that this request may be necessary for the approval of certain medical treatments, medications, or procedures.
I acknowledge that I am providing this consent voluntarily and that the information submitted as part of the prior authorization request is true and accurate to the best of my knowledge. I also understand that this process may involve the release of some of my health information as required by my insurance company or other entities involved.
Please be advised that Bottumzup Health and Wellness, LLC is not responsible for the approval or denial of prior authorizations. It is the patient's responsibility to ensure that their insurance provider approves the necessary prior authorization for treatment. We recommend verifying your coverage with your insurance prior to scheduling any procedures to avoid any unexpected charges.
By signing below, I authorize my healthcare provider to handle all aspects of the prior authorization process for the services I am seeking.

Thank you