NOTICES
Technical Advisory on Enrollee Consent for Provider-Initiated Grievances; Sample Enrollee Consent Form
[34 Pa.B. 3327] Under 28 Pa. Code § 9.603 (relating to technical advisories), the Department of Health (Department), Bureau of Managed Care, is issuing the following sample enrollee consent form for provider-initiated grievances. If a provider and enrollee follow its format, this consent form will be deemed by the Department to be compliant with 28 Pa. Code § 9.706 (relating to health care provider initiated grievances) and constitute valid enrollee consent for the purpose of a provider grievance.
Patient Consent for My Provider to
File a Grievance on my Behalf with my Health Insurance Plan
Provider Name: _________________ Provider Plan ID Number: _________________ Provider Address: ___________________________ Description of services that may be appealed: ______ Date(s) services were provided: ______ I agree to allow this health care provider to file a grievance on my behalf with the following health plan if there is a question about coverage for the services listed below.
I understand that:
1. If I consent, I will not be able to file my own grievance concerning these same services, nor will any representative I appoint, unless this consent is rescinded in writing.
2. I have a right to rescind this consent at any time. My legal representative has the right to rescind this consent at any time.
3. This consent shall be automatically rescinded if my health care provider does not file a grievance, or stops grieving my case.
I have read this consent or have had it read to me, and it has been explained to my satisfaction.
I understand the information in the consent form, and grant my consent to this provider to file a grievance on my behalf.
Print Patient Name: ______ Patient Date of Birth: _____ Health Insurance Company: ______ Patient Address: _________________ Patient Insurance ID Number: ______ Patient Signature: _________________ Signature Date: ______
The above named enrollee is unable to sign this consent form because of the following reasons and I consent for the
above named enrollee:Print Representative Name: ______ Relationship to the Patient: ______ Representative Signature: ______ Signature Date: ______
Print Witness Name: ______ Witness Signature: ______ Signature Date: ______
[Pa.B. Doc. No. 04-1151. Filed for public inspection June 25, 2004, 9:00 a.m.]
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