JDL Consent - DigniCap Hub

AUTHORIZATION AND CONSENT FOR PROTECTED HEALTH INFORMATION

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF INFORMATION (Privacy Rule, 45 C.F.R. §164.508)
Name(Required)
MM slash DD slash YYYY
PURPOSE OF DISCLOSURE: This authorization and consent is made in connection with my Precertification/Prior Authorization, appeal, grievance and/or independent review request related to insurance benefits and/or coverage.(Required)
Please check the box below in order to share information with JDL Access, LLC:(Required)
Please check the box below if you will share any of the below sensitive information:(Required)
METHOD OF DISCLOSURE: Disclosure may occur via secure email or fax, or by mail or other secure method agreed by JDL Access, LLC.(Required)

CONSENT FOR AUTHORIZED REPRESENTATIVE

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF INFORMATION (Privacy Rule, 45 C.F.R. §164.508)
If you would like to have a family member or friend assist you in this process, please check the box below which will allow JDL Access staff the ability to speak with someone else on your behalf.

CONSENT FOR JDL ACCESS, LLC TO BE AUTHORIZED REPRESENTATIVE TO SPEAK TO HEALTH INSURANCE CARRIER

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF INFORMATION (Privacy Rule, 45 C.F.R. §164.508)
I wish to designate JDL Access, LLC as my Authorized Representative to speak on my behalf to my health insurance carrier.

CONSENT TO LEAVE VOICEMAIL MESSAGES

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF INFORMATION (Privacy Rule, 45 C.F.R. §164.508)
Please check the box below if you consent to leave voicemail messages

Confirm Name(Required)