OAR Form - Patient Consent for Insurance Appeals

OAR - Patient consent for third party insurance appeals

Use this form to authorize Lakeview Clinic to file health insurance claim appeals on your behalf.

OAR Form

Provider Name

Provider Address

Description of services that may be appealed:

Date(s) services were provided:

First Name

Last Name

Patient Date of Birth:

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

I agree to allow this health care provider to file an appeal on my behalf with the following health plan if there is a question about coverage for the services listed above. I understand that if I consent, I will not be able to file my own appeal concerning these same services, nor will any representative I appoint, unless this consent is rescinded in writing. I have a right to rescind this consent at any time. My legal representative has the right to rescind this consent at any time. This consent shall be automatically rescinded if my health care provider does not to file an appeal or stops appealing my case.

I acknowledge I have read the above statement and understand the information in its entirety. In lieu of reading the above agreement, it has been read to me and explained to my satisfaction.

Signature

Date

Name of health insurance company

Patient's Insurance ID Number

Is the above name enrollee unable to sign this consent form?

Reason(s) enrollee cannot consent:

I consent, as a their representative, for the above named enrollee.

First Name

Last Name

Relationship to the patient

Representative Signature

Signature Date

Witness First Name

Witness Last Name

Witness Signature

Signature Date

OAR - Patient consent for third party insurance appeals

Use this form to authorize Lakeview Clinic to file health insurance claim appeals on your behalf.

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