MP+ Claim Form
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If this form is signed by someone other than the patient or parent, such as a personal representative, legal representative, or guardian on behalf of the patient, submit the following: a copy of
a health care representative form, power of attorney, a court order or other documentation showing custody, or other legal documentation showing the authority of the legal representative
to act on the patient’s behalf.
Version 0719IN01200803A190731
PART E. Privacy and Confidentiality Release Form
By completing this form, you are providing your consent for IMG to discuss information regarding your claim with the person(s) listed below. Without this written
authorization, applicable laws do not permit IMG to discuss information protected under confidentiality and privacy laws with anyone other than your physician(s)
or provider(s) of service.
I authorize IMG to discuss my claim with ____________________________________ who is ______________________________________________
This authorization is valid for __________ months from the date signed (maximum of 12 months).
I give IMG permission to release
the following information:
(Please select and initial)
________________ Financial and claim information related to medical bills or claim form.
________________ Provider name, date of service, total charge, total amount paid, and date of payment.
________________ Insurance ID number and/or patient account number
Privacy and confidentiality laws do not permit the release or re-disclosure of medical records obtained from a medical provider. Your medical information
and records can be obtained directly from your medical provider.
I have read the contents of this form. I understand, agree, and allow IMG to use and release of my information as I have stated above. I also understand that
signing this form is of my own free will. I understand IMG does not require that I sign this form in order for me to receive treatment, payment, or for enrollment
or being eligible for benefits. I have the right to withdraw this approval at any time by giving written notice of my withdrawal to IMG. I understand that my
withdrawing this approval will not affect any action taken before I do so. I also understand that information that’s released may be given out by the person
or group who receives it. If this happens, it may no longer be protected under the HIPAA Privacy Rule. I am entitled to a copy of this form.
Print Patient Name: _________________________________________________________
Insurance ID Number:
Signature of the Patient or parent if the patient is a minor child: X _______________________________________
Date: ___/___/___ (MM/ DD/YYYY)
PART D. AUTHORIZATION—to be completed by the claimant for all claims.
I verify that all information contained in this form is true, correct and complete to the best of my knowledge. I authorize any health plan, health care provider,
health care professional, MIB, federal, state or local government agency, insurance or reinsuring company, consumer reporting agency, employer, benefit plan,
or any other organization or person that has any records or knowledge of my health, has any information available as to diagnosis, treatment and prognosis
with respect to any physical or mental condition and/or treatment of me, and any non-medical information about me, to disclose my entire medical record, file,
history, medications, and any other information concerning me and to give any and all such information to my agent of record and authorized representatives of
Company, IMG, and their affiliates, and subsidiaries. Individuals have the right to refuse to sign the authorization without negative consequences to treatment or
plan enrollment, except IMG will not be able to administer claims, determine benefit eligibility, or issue payments. The authorization is valid for the term of the
insurance contract or plan under which a claim has been submitted.
I understand that I have the right to receive a copy of this authorization upon request and revoke the authorization at any time in a written communication to
IMG. A copy of this shall be as valid as the original. I acknowledge and understand there is the potential for the information to be subject to re-disclosure by the
recipient and to no longer be protected by applicable privacy and confidentiality laws.
Any person who knowingly presents a false or fraudulent claim for payment of a loss of benefit or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Print Name of Insured: __________________________________________________________________________________________________________
Signature of Insured/Legal Representative: X _______________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
AUTHORIZATION:
I authorize payment of any benefits for eligible medical expenses to the provider or other supplier of services which is entitled to payment of the attached bills.
Signature of the Insured/Legal Representative: X ___________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
If needed you can overnight packages to following address:
2960 North Meridian Street, Indianapolis, IN 46208
