Patient Consent - Illinois CancerCare

The purpose of this form is to authorize Argenta Advisors, Inc. (Argenta) to help you attempt to obtain insurance coverage for PET imaging with PYLARIFY® (piflufolastat F 18) injection. It allows Argenta to act on your behalf and to take certain actions that are described below for the purpose of attempting to obtain insurance coverage. It also allows your health plan(s) to communicate with Argenta, although your health plan may also require that you sign its form as well.

Download Form

"*" indicates required fields

Required fields marked with a *

Member (Patient) Name*

First Last

Date of Birth*

I want to and hereby allow Argenta Advisors, Inc. to be my Designated Authorized Representative. I request and authorize my representative to perform the following for me:

Request that my health plan(s) review my eligibility for coverage of the product and(or) service
Request that my health plan(s) reconsider or issue an individual consideration for coverage of the surgical procedure for me, if necessary
Obtain, share, release, and discuss protected health information (PHI) about me and my health care
Ask my health plan(s) to conduct an external review of its decision, if necessary
File a grievance with my plan(s) regarding its decision not to cover the procedure or its failure to issue a decision about coverage, if necessary
File a grievance with my local insurance commissioner if my health plan(s) fails to honor the request for an external review
Assist with drafting letters, complete and send forms necessary to attempt to obtain coverage for the product and/or service

Today's Date*

Member or Legal Representative's Signature

Legal Representative's Name (if applicable)

Member's Email Address

Member's Daytime Phone Number

Member's Evening Phone Number

Member's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name

This field is for validation purposes and should be left unchanged.