Patient Consent

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.

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Member (Patient) Name*
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
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Member's Address
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