Attestation to Discharge | Share Wellness Center
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Online Referral
Attestation to Discharge
Attestation to Discharge
Conflicting/Overlapping Authorization(s) Due to Non-Overlap Requirement
Home » Attestation to Discharge
Share Wellness Center
Attestation to Discharge Conflicting/Overlapping Authorization(s) Due to Non-Overlap Requirement
Participant Information
Participant Information
Participant Full Name
Participant ID
Date of Birth
Provider Information
Provider Organization Name
Provider NPI / Provider Identifier
Provider TIN Number
Purpose
Certain services are not permitted to overlap according to COMAR 10.09.80.06B. You can also refer to the Combination of Mental Health Services document or the Combination of SUD Services document on Share Wellness Center's website for additional details.
This attestation documents the participant's (or Authorized Representative's) request to receive services with the provider listed above and to discharge/end any conflicting, overlapping authorization(s) that prevent authorization and/or delivery of those services.
If the participant has any questions, they can call customer service at +1 (240) 355-1616 to ask for additional details.
A) Participant / Authorized Representative Attestation
By signing below, I attest and agree that:
1. I am (check one):
The participant identified above
The participant's Authorized Representative/legal guardian with legal authority to act on the participant's behalf
2. I am requesting to receive the indicated behavioral health service(s) with the provider identified above.
3. I understand that certain service authorizations may not overlap, and that existing overlapping authorizations may prevent the requested services from being authorized and/or delivered from this Provider.
4. I am requesting that any conflicting and overlapping authorization(s) (including those associated with other provider(s)) that are not permitted to overlap with the services I am seeking with this provider be discharged/ended/closed, as allowed under program rules, so that services may proceed with this provider. I understand that conflicting and overlapping authorizations will be discharged/ended/closed immediately upon submission of this document.
5. I understand that ending/discharging an authorization may affect the participant's ability to receive services under the discharged authorization(s). I have had the opportunity to ask questions about this decision and have received answers I understand.
6. I attest that this decision is voluntary and made without coercion.
Printed Name (participant or Authorized Representative)
If Authorized Representative, relationship to participant
If Authorized Representative, brief description of authority
Signature (wet signature only)
Date Signed (MM/DD/YYYY)
B) Provider / Authorized Provider Representative Attestation
By signing below, I attest and agree that:
1. I am the provider or an Authorized Representative of the provider identified above, and I am authorized to sign this attestation on behalf of the Provider.
2. The participant (or Authorized Representative) completed this attestation in concert with the provider and affirmed they are seeking services with this Provider.
3. To the best of my knowledge, the participant may have an existing authorization(s) that conflicts with the non-overlap requirement for the service(s) being sought with this provider, and this attestation is intended to document the participant's request to discharge/end such conflicting, overlapping authorization(s) (including authorization(s) associated with other provider(s)).
4. I informed the participant (or Authorized Representative) that discharging an authorization may affect access to services under the discharged authorization(s) and provided an opportunity for questions.
Printed Name (Provider/Representative)
Title
Signature (wet signature only)
Date Signed (MM/DD/YYYY)
Submit Attestation Form
Print Form
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function submitAttestation() {
function val(id) {
var el = document.getElementById(id);
return el ? el.value.trim() : '';
}
var body = 'ATTESTATION TO DISCHARGE - SHARE WELLNESS CENTER\n'
+ '================================================\n\n'
+ 'PARTICIPANT INFORMATION\n'
+ 'Name: ' + val('aParticipantName') + '\n'
+ 'Participant ID: ' + val('aParticipantId') + '\n'
+ 'Date of Birth: ' + val('aDob') + '\n\n'
+ 'PROVIDER INFORMATION\n'
+ 'Organization: ' + val('aProviderOrg') + '\n'
+ 'NPI/Identifier: ' + val('aProviderNpi') + '\n'
+ 'TIN: ' + val('aProviderTin') + '\n\n'
+ 'SECTION A - PARTICIPANT ATTESTATION\n'
+ 'Printed Name: ' + val('aPrintedNameA') + '\n'
+ 'Relationship: ' + val('aRelationship') + '\n'
+ 'Authority: ' + val('aAuthority') + '\n'
+ 'Signature: ' + val('aSignatureA') + '\n'
+ 'Date Signed: ' + val('aDateSignedA') + '\n\n'
+ 'SECTION B - PROVIDER ATTESTATION\n'
+ 'Printed Name: ' + val('aPrintedNameB') + '\n'
+ 'Title: ' + val('aProviderTitle') + '\n'
+ 'Signature: ' + val('aSignatureB') + '\n'
+ 'Date Signed: ' + val('aDateSignedB') + '\n\n'
+ '================================================\n'
+ 'Submitted on: ' + new Date().toLocaleString();
var mailtoLink = 'mailto:info@sharewellnesscenter.com'
+ '?subject=Attestation to Discharge - ' + encodeURIComponent(val('aParticipantName') || 'Share Wellness')
+ '&body=' + encodeURIComponent(body);
window.location.href = mailtoLink;
}
