Consent to Release Medical Information

I give Special Products, LLC, my written consent to release medical information to medical contract providers, including the Department for Children and Families. This consent allows Special Products, LLC, to make claims for payment and request payment of medical benefits to Special Products, LLC, for services rendered. Consumers may be billed for Medicaid covered services in the following circumstances when notified in writing by the provider:

  • The consumer was not eligible for Medicaid when the service was provided.
  • The consumer was eligible, but failed to notify the provider of eligibility in a timely manner.
  • Services Medicaid does not cover unless the consumer is a Qualified Medicare Beneficiary and the services is covered by Medicare.
  • Services in which the provider failed to meet program requirements.
    When other insurance does not reimburse because there was a lack of authorization.

Consent to Use & Discharge of Health Information for Treatment, Payment or Healthcare Operations

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examinations and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:

1. a basis for planning my care and treatment

2. a means of communication among the many health professionals who contribute to my care

3. a source of information for applying my diagnosis to my bill

4. a means by which a third party can verify the services billed were actually provided

5. a tool for routine healthcare operations such as assessing quality

I understand that I have been provided a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to the address I have provided. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization as already taken action in reliance thereon.