If known, please include procedure codes (CPT) and proposed rates which are applicable to the member's treatment. Not all codes are covered by all Plans and may be subject to additional authorization requirements. All services must be Medically Necessary.
If known, please include all procedure codes (Revenue or HCPCS), service description, and proposed rates which are applicable to the member's treatment. Not all codes are covered by all Plans and may be subject to additional authorization requirements. All services must be Medically Necessary.
To evaluate your request for a Single-Case Agreement (SCA), Quest may need to obtain information from your treating provider regarding planning for your care and to determine coverage, including your treatment history. This information is considered your Protected Health Information (PHI). By completing the section below and signing this form, you are allowing your providers to release your Protected Health Information to Quest. We will only contact the provider(s) listed below and only to review information needed to facilitate your SCA request. Quest Behavioral Health values and respects your privacy and will not disclose your information except as specifically outlined below. All PHI is protected as required by federal HIPAA regulations. This consent expires one year from the date of signature below.
By my typed signature below, I am authorizing the provider(s) listed to disclose my PHI (or the PHI of minor member for whom I am a legal guardian), to Quest Behavioral Health. I understand that this information will be used to review my request for a Single-Case Agreement. I understand that my provider(s) may not require me to sign this form to continue treatment, but my request for SCA coverage will be denied if I do not sign this form.
Purpose of the Disclosure: To allow Quest to receive all PHI needed to make decisions regarding my Single-Case Agreement request.
Right to withdraw consent: I understand I may revoke this consent at any time by submitting a written statement to Quest Behavioral Health. I understand that withdrawing my consent does not prevent the release of or apply to information that has already been released as authorized by this consent.
Right to obtain a copy of Informed Consent: I understand that I may request a copy of this consent form to be provided at no cost to me. Copies of signed consent(s) may be obtained by contacting Quest at 800-364-6352.
By typing your name below, you acknowledge that this electronic signature bears the full legal equivalent of a manual signature.