Standalone Coordination & Authorized Representative Consent
(v2025-08-21)
Effective Date: August 21, 2025
Authorized Representative (Eligibility/Referrals) (Medicare)
(Brief Summary - See full authorization below)
You may authorize ShadowNurse ("SN") to act as your authorized representative for eligibility/benefits checks, appeals/grievances, scheduling/referrals, and coordination with medical device vendors to establish RPM/RTM support services ordered by a clinician. This does not assign benefits or authorize billing by SN, and you may revoke at any time.
Medicare Eligibility & Benefits Authorization — Patient Self-Referral
(Brief Summary - See full authorization below)
I authorize ShadowNurse (“SN”) to verify my Medicare (including Medicare Advantage/Part C) eligibility and benefits with CMS, Medicare Administrative Contractors, and/or my health plan, using third-party connectivity vendors as needed, including HIPAA-standard 270/271 transactions. This authorization allows SN to use the eligibility/benefits information for initial and ongoing coordination, scheduling, and referrals with independent clinical entities. This does not assign benefits or authorize billing by SN, and I may revoke at any time.
Medicare Eligibility & Benefits Authorization — Caregiver Referral
(Brief Summary - See full authorization below)
I am submitting this referral on behalf of the patient and authorize ShadowNurse (“SN”) to verify the patient’s Medicare (including Medicare Advantage/Part C) eligibility and benefits with CMS, Medicare Administrative Contractors, and/or the health plan, using third-party connectivity vendors as needed, including HIPAA-standard 270/271 transactions. This authorization allows SN to use the eligibility/benefits information for initial and ongoing coordination, scheduling, and referrals with independent clinical entities. This does not assign benefits or authorize billing by SN, and it may be revoked at any time by the patient or legal representative.
I am authorized to act for the patient as (select one): ☐ Patient is present and gives consent now ☐ Legally authorized representative (e.g., POA/guardian) — documentation available ☐ Involved caregiver/family member with patient’s agreement under HIPAA §164.510(b)
What HIPAA §164.510(b) Permits
This section of the HIPAA Privacy Rule allows covered entities (like hospitals and doctors' offices) to share protected health information (PHI) with family members, close friends, or other persons identified by the patient, as long as the information is relevant to that person's involvement in the patient's care or payment for care.
Standalone Coordination & Authorized Representative Consent
Purpose. I authorize ShadowNurse, Inc. ("SN") to act as my authorized representative to: (a) verify initial and ongoing eligibility and benefits with Medicare, Medicare Advantage (Part C), and/or my health plan(s); (b) assist with appeals, grievances, and prior authorization processes; (c) coordinate scheduling and referrals with independent medical groups and clinicians; (d) request and receive medical records from my providers for care coordination; and (e) communicate with medical device vendors to help establish and support Remote Patient Monitoring (RPM) and/or Remote Therapeutic Monitoring (RTM) services as ordered by a licensed clinician (including device selection, enrollment, activation, education, and required documentation).
Scope and limits. This authorization permits SN to use third‑party connectivity vendors to submit eligibility/benefit inquiries (HIPAA-standard 270/271 transactions) and to receive responses from payors, and to exchange necessary information with my plan(s), providers, and device vendors to carry out the purposes above. This authorization does not assign insurance benefits or payments to SN and does not make SN a billing provider. Clinical billing, if any, is performed by the independent rendering entity and/or vendor.
Duration and revocation. This authorization is effective on the date signed and remains in effect until revoked. I may revoke it at any time by written notice to SN; revocation will not affect actions already taken in reliance on this authorization.
Digital copy. A digital or facsimile copy of this authorization is as valid as the original.
Authorization and Signature
Printed Name: ___________________________ Date of Birth: ___________________________ Mobile Number: _________________________ Signature: ______________________________ Date: ___________
Usage example: Use this one‑page consent when SN needs to communicate with payors or medical device vendors about a member’s account, eligibility, or device enrollment for RPM/RTM, and when a vendor or plan requires a signed authorization beyond SN’s ToS consent. It also supports record requests for care coordination when a provider’s NPP/BAA framework does not fully cover SN’s role.