Procedure Forms

We encourage you to review the following forms for more information. Feel free to email any completed forms or questions to our office at info@sierramedservices.com

FORM 1:

SierraMed Services Procedure Guidelines

This form provides information about our procedure guidelines. It gives an overview of what to expect during each step of the process, including the steps you should take to move your case forward.

FORM 2:

Patient Procedure Request and Acceptance/Denial

Review and fill out this form to request that we cover the costs of a medical procedure recommended by your physician.

FORM 3:

Authorization for Release of Health Care Information

Complete this form to authorize the release of Protected Health information pursuant to 45 CFR 160 and 164 and any information sensitive under 42 CFR. For a Spanish-language version of this form, click here.

FORM 4:

Medical Lien

Please review and complete this form to grant Sierra Medical Services a medical lien, enabling patients to secure compensation before the claim is settled. Once the patient recovers compensation through a settlement or award, they agree to repay Sierra Medical Services the amount owed. A Spanish-language version of this form is available here.

FORM 5:

Individual Assignment of Account Receivable

This form requires the Provider to attest to the validity of the information provided on the form and to clarify that the Qualifying Patient’s Account Receivable is not delinquent or in default. By signing this form, the Provider assigns, grants, transfers, and conveys the Account(s) receivable to Sierra Medical Services, LLC.