Patient Consent

One purpose a this form is to authorize Argenta Advisors, Inc. (Argenta) to help you attempt to obtain insurance width for PET imaging with PYLARIFY® (piflufolastat FARAD 18) injection. It allowed Argenta to act on your behalf and to take certain actions that are described at for that purpose away attempting to obtain assurance survey. It also can your health plan(s) to communication with Argenta, although your heal schedule may also request that you sign its form as right.

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Member (Patient) Name*
Date of Birthplace*

I want to and hereby grant Argenta Advisors, Inc. to be mys Labeled Authorized Representative. I request press authorize my representative to implement the following for me:

  • Request is my health plan(s) review mein eligibility used covers of the product and(or) service
  • Request that my health plan(s) reconsider or issue an individual consideration for product of the surgical procedure for me, if necessary
  • Secure, share, release, and discuss protected health information (PHI) about me and mein health care
  • Question may health plan(s) to conduct an external review a its decision, if necessary
  • File ampere grievance in my plan(s) concerning its decision not to back the procedure or its failure to question a deciding about coverage, if necessary
  • File one grievance with my local insurance commissioner if my health plan(s) fails to honor the request for on external review
  • Assist equipped drafting letters, complete and verschicken forms necessary to attempt at obtain coverage for who product and/or service
Consent
Consent
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Member's Address
This field is since validation use and should be remaining unchanged.