Forms & Agreements

What is the single most important issue you want addressed first? In alignment with The Care Access Method, we resolve your primary barrier first before reviewing secondary logistical concerns.

Why are you seeking help now? (Check all that apply)

• New diagnosis
• Denial received
• Appeal denied
• Treatment delay
• Provider unable to assist
• Unsure of next steps
• Other

Financial Impact Assessment — What happens if this is not approved?

• Delayed treatment
• Worsening condition
• Loss of employment
• Out-of-pocket expense
• Reduced treatment options
• Other

Desired outcome — what would success look like to you?

• Approval of denied service
• Earlier specialist access
• Coverage pathway identified
• Alternative treatment access
• Appeal strategy developed
• Understanding available options

Is there a scheduled procedure, treatment, or appointment that could be affected?

• Yes
• No

Denial history

• Have you received a formal denial letter?
• Can you upload / provide the denial letter?
• Have you already attempted an appeal?

Healthcare providers involved

Plan type

• Commercial / Employer plan
• Marketplace / ACA plan
• Medicare
• Medicaid
• Other

Network structure

• PPO
• HMO
• EPO
• POS

I hereby authorize any licensed physician, medical professional, hospital network, specialty clinic, medical pharmacy, medical billing entity, or health insurance provider involved in my care or coverage determinations to disclose the designated PHI records described below.

The records below may be disclosed to, shared with, and discussed with:

Check all communication methods you authorize for coordinating, transmitting, or discussing your PHI.

• Phone calls / voice messages
• Email correspondence
• Secure patient portal correspondence
• Text messaging (SMS)

Check each administrative category you authorize for disclosure.

• All comprehensive medical records (clinical notes, histories, specialist evaluations, imaging summaries)
• Health insurance carrier records (prior authorizations, denial notices, appeals, internal reviews)
• Billing, financial & claims data (itemized bills, statements, payouts, balance sheets)

Right to revoke. I may revoke this authorization in writing at any time by delivering a signed revocation letter to my Advocate and disclosing providers. Revocation does not affect disclosures made before written notice was received.

Condition of treatment. Providers cannot condition treatment, payment, enrollment, or benefits on whether I sign this authorization.

Expiration. Unless revoked sooner in writing, this authorization expires one (1) year from the date of signature, or upon the event below:

By signing below I certify I have read this document, understand my legal rights regarding data disclosure, and grant consent for the communication methods checked above.

The Client is purchasing a short-term consulting engagement limited to the following deliverables:

• One (1) primary healthcare challenge — focus is strictly dedicated to a single, primary barrier identified by the Client at intake.
• One (1) Strategic Access Portfolio — a compiled set of personalized navigation pathways and administrative options.
• One (1) intake session — structured initial assessment of timeline and documents.
• One (1) strategy delivery session — presentation of the Strategic Access Portfolio.
• Up to thirty (30) days of email support — brief administrative correspondence beginning at the strategy delivery session.
• Barrier and pathway identification — administrative analysis of logistical hurdles.

Not included in this service

• Legal representation or formal legal advocacy in any court or administrative body.
• Medical advice, clinical evaluation, or clinical care coordination.
• Direct medical treatment or physical triage.
• Guarantee of approval, financial payout, or insurance overturning.
• Ongoing case management, subsequent appeals, or representation regarding new medical events beyond the 30-day email support period — these require a separate written agreement.

• Engagement fee. A flat, fixed fee of $3,000.00 is due and payable in full prior to the commencement of any services, document review, or scheduling of sessions.
• Non-refundability. The fee is fully earned and non-refundable upon the Advocate initiating records review. If cancellation occurs before records review begins, a refund may be issued less a standard administrative processing fee.
• Additional matters. Separate diagnoses, subsequent denials, or auxiliary administrative barriers arising during this engagement are not covered and require a separate written engagement.

A. No legal representation

The Advocate is not a licensed attorney and does not provide legal advice, contractual analysis, or legal defense. No attorney-client relationship is formed or implied. For legal matters, consult a licensed attorney or your state Bar association.

B. No guarantee of outcome

All final authorization decisions, coverage determinations, and medical exception policies are governed by independent third parties, regulatory bodies, or insurance companies. The Advocate provides no guarantee regarding final approvals.

C. Responsibility for medical decisions

The Client remains solely responsible for all medical and clinical decisions. The Advocate operates strictly in a non-clinical, educational, and administrative navigation capacity and does not replace the advice of licensed healthcare professionals.

By signing below, the parties confirm they have read, understood, and agreed to every condition, payment restriction, and scope boundary in this agreement.