Cardiovascular Rehabilitation Billing Authorization Form

This cardiovascular rehabilitation billing authorization form is essential for cardiac rehab centers, hospital-based rehab programs, and outpatient cardiovascular services managing the complex billing requirements of medically supervised exercise therapy. The form addresses Medicare's specific coverage criteria for cardiac rehab, including qualifying diagnoses like myocardial infarction, coronary bypass surgery, stable angina, and heart valve repair. It streamlines the authorization process for the standard 36-session protocol and potential extensions.

The template includes sections for qualifying cardiac event documentation, physician referral verification, insurance pre-authorization tracking, session-based billing agreements, and patient financial responsibility for non-covered services. It helps cardiac rehab programs ensure proper reimbursement while maintaining compliance with Medicare guidelines and commercial payer requirements. The form also addresses bundled payment models, secondary insurance coordination, and patient payment plans for deductibles and co-payments associated with extended rehab programs.