The easiest way to do this is as a new "Consent Document."
Settings / Client Communication / Client Portal / Shared Documents and Files / +Consent Document.
Make sure it's Defaulted to "yes" if you want all new clients to get it. It's only required by TriWest, but is actually beneficial to receive from everyone in Medicare / VA / Active Duty.
Under all existing (TriWest or all) clients' profiles, click on the "Share" button in the upper right-hand corner.
This form captures the signature and date and puts it right into the chart under "Uploaded Files" in case you are audited by TriWest or required to provide it to anyone.
ASSIGNMENT OF BENEFITS / SIGNATURE ON FILE
I request that payment of authorized insurance benefits, including Medicare, VA, or Active Duty Military, if I (or my dependent: spouse, child, other) am a Medicare, VA, or Active Duty Military beneficiary, be made on my behalf to [INSERT PRACTICE] for any medical services provided to me (or my dependent: spouse, child, other) by that organization.
I authorize the release of any and all medical or other information necessary to determine these benefits or the benefits payable for related equipment or services to the organization, the Health Care Financing Administration, my insurance carrier and/or other medical entity. A copy of this authorization will be sent to the Health Care Financing Administration, my insurance company and/or other entity, if requested or required. The original will be kept on file by the organization.
I understand that I am financially responsible to the organization for any charges not covered by health care benefits. It is my responsibility to notify the organization of any changes in my (or my dependent: spouse, child, other) health care coverage. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form, I am accepting financial responsibility as explained above for all payments for all products and services received.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT, AND THIS IS MY ELECTRONIC SIGNATURE.
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