Authorization for Release:
I hereby authorize the above-named Practice to release my Protected Health Information (PHI) as described below to PRIA HEALTHCARE MANAGEMENT (“PRIA”), and Avation Medical, Inc., and their employees/business associates as requested by them for the purpose of and in connection with my precertification, appeal, grievance and/or independent review request of a denial of insurance benefits and/or coverage, including but not limited to:
MEDICAL RECORDS: Hospital records, chart and notes; laboratory records and reports; physical therapy records; doctors and nurse’s notes; all correspondence of any kind; mental health, psychiatric and psychological records; substance abuse information; reports, tests, and test results, x-ray films and reports; and, any and all other records which pertain to my medical care, treatment, history and prognosis.
INSURANCE/BILLING RECORDS: Any and all communications, notes, billing statements, claim forms, Explanation of Benefits, enrollment information, premium information or other benefits information or documents to/from insurance companies, self-insured plans, TPA’s, claims administrators, Plan Sponsors, Plan Administrators, utilization review companies or other third-party payers involved with evaluating, adjusting, processing or paying my claim(s) for insurance benefits, whether pre-service or post-service in nature.
Additional Notices
I understand that signing this form is voluntary. I understand that my health information may be protected by HIPAA (45 CFR Parts 160 and 164), the Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR Part 2), and/or state laws. I understand that my health information may be subject to re-disclosure by the recipient and that if the organization or person authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by the federal privacy regulations. I understand that my records may contain information regarding my mental health, substance use or dependency, or sexuality, and also may contain confidential HIV/AIDS-related information. I further understand that by signing below, I am authorizing the release or exchange of these records to the parties named above. I also understand that my covered entity may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this form. Any copies of this Authorization and Appointment of Representative shall be treated in all respects as though an original, including facsimile transmissions, thereof. I have been advised of my rights to receive a copy of this form.
Expiration: The above Authorization and the below Appointment of Representative will expire one year from the date entered below OR upon conclusion of my appeal process.
Revocation: I understand that I may revoke the above Authorization and/or the below Appointment of Representative at any time by notifying PRIA, in writing, to the e-mail address listed above. However, I understand that if I revoke the Authorization and/or my Appointment of Representative, it will not have any effect on any actions PRIA or Avation Medical, Inc., took before PRIA received the revocation.
