A consent form is required when you submit an electronic payment request or predetermination on behalf of your patient. You must use the electronic transmission authorization and consent form to obtain an insured member’s consent to submit claims on their behalf or that of a family member, and to receive payment from their insurer. The form contains two sections that are completed by the insured member—or in the case of a minor, by the parent or guardian:
The Consent to collect and exchange personal information section grants you permission to submit the patient’s healthcare payment and predetermination requests electronically.
The Benefit assignment form records your patient’s understanding of how the payment is assigned. It is completed when payment is assigned to you or your clinic.
This document should be printed, signed, and kept on file for seven years. A new signature is required whenever the information collected on the form changes.
Consent forms are not pre-filled, as they are meant to be completed by your patient or your patient’s parent/guardian, and signed by the insurer.
Note: You must ask your patient or your patient’s parent/guardian for permission to submit their healthcare payment request or predetermination electronically. You must also ask their permission every time they wish to assign the payment over to the provider (or the provider’s organization).
Accessing consent forms
From the eClaims application, click the Forms tab.
The applicable forms are displayed.
To download a form, click the appropriate link, then use your browser's print or save buttons to print or save it.
You can also access the consent form directly by clicking here.