Electronic Transmission Authorization And Consent Form printable pdf download

Electronic Transmission Authorization and Consent Form

Instructions: This form must be filled out when claims are submitted electronically by the provider on the

patient’s behalf. Please retain this form in the patient’s file for verification purposes for two years

following closure of the patient file.

Provider: ______________________________________

Address: _______________________________________

City/Province: ___________________________________

Postal Code: ____________________________________

Phone Number: __________________________________

Patient: ________________________________________

Address: ________________________________________

City/Province: ____________________________________

Postal Code: _____________________________________

Phone Number: ___________________________________

Plan Number: ____________________________________

Certificate / Plan member Number: ___________________

Consent to Collect and Exchange Personal Information

Message to the Plan member, Spouse and/or Dependent regarding Personal Information

Personal information that we collect and disclose about you, and if applicable, your spouse and/or

dependents, is used by the insurer and/or plan administrator and their service provider(s) for the

purposes of assessing your claims, underwriting, investigating, auditing and administering the group

benefits plan, including the investigation of fraud and / or plan abuse.

Authorization and Consent

I authorize my healthcare provider to collect, use and disclose personal information concerning any

claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for

the above purposes.

I authorize the insurer and / or plan administrator and their service provider(s) to:

use my personal information for the above purposes.

exchange personal information with any individual or organization, including healthcare

professionals, investigative agencies, insurers and reinsurers, and administrators of government

benefits or other benefits programs when relevant for the above purposes.

exchange personal information concerning any claims submitted with the plan member or a

person acting on behalf of the plan member.

exchange personal information for the above purposes electronically or in any other manner.

I understand that personal information may be subject to disclosure to those authorized under applicable

law.

I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and

may remain in effect for the continued administration of the group benefits plan.

Electronic Transmission Authorization And Consent Form