Authorization To Bill Health Insurance / Assignment of Benefits
Release of Medical and Billing Information
In consideration of services provided by 1st Care Management (1CM), the Patient or undersigned representative acting on behalf of the Patient agrees and consents to the following:
I do hereby give full permission and authorize 1st Care Management, to bill my insurance for services rendered to me or my dependent(s) by 1st Care Management. I also agree to have any checks or payment made by said insurance company to be payable and deliverable to: 1st Care Management, 1120 Hope Rd., Sandy Springs, GA 30350
I understand that I am responsible for understanding information about my health insurance policy and providing such information to 1st Care Management, for correct billing. I am also responsible to notify 1st Care Management in the case of change of my health insurance status – inclusive benefits and any information I receive relating to care I have or will receive in this office.
I understand that 1st Care Management will be providing services and billing my health insurance for those services at various times during the course of my care at this office. I understand that ultimately I am responsible for all payments relating to any and all charges relating to treatment and services that I have received at 1st Care Management during my care. I also understand that my insurance company and related policy plan may offer benefits for services provided at 1st Care Management, but that such benefits do not necessarily guarantee payment for those services.
I understand that the policy of 1st Care Management requires payment in full for all services rendered at the time of visit, unless other financial arrangements have been made. If my account is not paid within 90 days of the date of service and no other financial arrangements have been made, I will be responsible for all legal fees, collection agency fees, and any other expenses incurred in collecting my account.
I understand the above information and agree that my health history and related information was completed correctly to the best of my knowledge and understand that it is my responsibility to alert 1st Care Management of any change in my medical status or insurance coverage.
I hereby release 1st Care Management, its officers, agents, employees and any clinical staff associated with my case, from all liability that may arise as a result of disclosure of information to the above named insurance company(s) or their designated representatives:
- I am aware and understand that this authorization will not be used unless the above named insurance company(s) or their designated representatives request records of information for reimbursement purposes; or seek to take action reference payment for treatment services.
- I agree to participate and assist 1st Care Management or its designated representatives with any appeal process necessary to collect payments for services rendered.
- I am aware and have been advised of the provisions of Federal and State Statutes, rules and regulations and provide for my right to confidentiality of these records.
- I understand that this assignment and authorization is subject to revocation at any time except to the extent that action has been taken in reliance thereof. In any event, this authorization will expire once reimbursement for services rendered is complete.
- 1st Care Management is filing for insurance benefits for the services performed and it can assume no responsibility for guaranteeing payment of any charges from the insurance company(s).
- A firm contracted by 1st Care Management for billing and collection purposes may do billing.
- 1st Care Management is appointed by me to act as my representative and on my behalf in any proceeding that may be necessary to seek payment from my insurance carrier. This includes receiving a copy of my insurance plan’s documents.
- Should an overpayment take place, a refund check will be mailed to the authorized party that is due the overpayment.
- 1st Care Management shall be entitled to the full amount of its charges without offset.
The undersigned does agree to observe and abide by all of the statements made above.
Patient Financial Agreement and Responsibilities
1st Care Management (1CM) is committed to providing patients with information regarding their coverage and financial responsibilities. In consideration of services provided by 1CM, the Patient or undersigned representative acting on behalf of the Patient agrees to the following:
1. Non-Medicare Patient Responsibility for Payment
In return for Medical Treatment/Services rendered to the Patient, Patient understands and unconditionally agrees to the following:
- Patient agrees to pay all co-payments, deductibles or co-insurances.
- Patient understands and agrees that he/she will be charged the 1CM standard charge master rates for all services not covered by a Payor or that are self-pay.
- Patient understands that he/she may qualify for financial assistance. Patient may contact the office manager at 1CM to discuss potential benefits Patient may qualify for to cover the cost of services.
- Patient specifically agrees to pay for any services, which are determined not to be covered by any health benefit plan or insurance company, including emergency medical services after Patient has been treated and stabilized.
- Patient is aware that he/she is not relieved of liability by any extension of time granted for the payment of these charges, not by the acceptance by the 1CM of a note of the patient or any third person.
- If 1CM requires legal assistance to collect an account, Patient agrees to pay the cost incurred for such collections.
- 1CM may use data from third parties such as credit reporting agencies in order to verify demographic data or evaluate financial options and by this authorization expressly permit sources and employers to provide 1CM with all information requested.
2. Assignment of Insurance or Health Plan Benefits
Patient acknowledges the assignment and authorization for direct payment to 1CM for all insurance and health plan benefits and settlements whether hospital, medical or liability insurance including but not limited to, the proceeds of any settlement or judgment of any third party claim as payment for any and all services performed at 1CM. Patient agrees that the insurance company’s or health plan’s payment to 1CM pursuant to this authorization shall discharge the insurance company’s or health plan’s obligations to the extent of such payment.
3. Filing of Third Party Claims
Patient acknowledges that upon proof of coverage, 1CM will submit a claim for payment of insurance benefits and accept payments from third party payors (“Payors”) to be credited to Patient’s account as they are received. Patient agrees that the filing of insurance claims is performed as a service and in no way relieves Patient of the obligation to pay in full. Additionally the Patient acknowledges the following:
- Patient is responsible to follow up with any insurance company or employer within 30 days to see that Patient’s bill is paid promptly.
- Patient understands that he/she is financially responsible for charges not paid according to this agreement. If Patient overpays the amount owed on his/her account, Patient assigns credit to be applied to any other existing unpaid accounts (“Other Accounts”) for which the Patient or the insured or guarantor is also responsible. Any money remaining after the Patient’s account and Other Accounts have been paid in full will be refunded to the patient or guarantor.
- Insurance companies will often deny claims when the insurance is not presented at the time of service. Patient must present 1CM with his/her insurance at the time of the appointment or Patient will be considered self-pay/uninsured and responsible for the total bill.
4. Assignment of Medicare Benefits
Patient certifies that the information given in applying for payment under Title XVIII of the Social Security Act is correct. Patient requests that the payment of authorized benefits be made on Patient’s behalf to the provider of Medical Treatment/Services. Patient assigns the benefits payable for Medical Treatment/Services rendered by 1CM and all Healthcare Professionals rendering care and/or treatment to Patient and authorizes 1CM and Healthcare Professionals to submit claims to Medicare for payment. Patient authorizes any holder of medical or other information to release to Medicare and its agents any information needed to determine these benefits or benefits for related services. Patient understands he/she is responsible for any deductibles, co-payments and/or non-covered services as defined by Medicare to be paid in accordance with all terms and conditions specified herein.
5. Assignment of Medicaid Benefits
Patient certifies that the information given in applying for payment under Title XIX of the Social Security Act is correct. Patient authorizes any holder of medical or other information to release to the Social Security Administration or its intermediaries or carriers any and all information needed for this or related Medicaid claims. Patient requests payment of authorized benefits be made on Patient’s behalf to the provider of Medical Treatment/Services. Patient assigns the benefits payable for Medical Treatment/Services rendered by 1CM and all Healthcare Professionals rendering care and/or treatment to Patient and authorizes 1CM and Healthcare Professionals to submit claims to Medicaid for payment.
6. Canceled Home Visits
Patient understands that 1CM will charge Patient a $150 fee for every home visit Patient cancels without providing 1CM with at least 48-hours notice.
7. Authorization to Release Information
1CM is authorized to release information contained in the patient record. The information authorized to be released shall include, but is not limited to, infectious or contagious disease information, including HIV or AIDS-related evaluations, diagnosis or treatment; information about drug or alcohol abuse or treatment of the same and/or psychiatric or psychological information.
Patient waives any privilege pertaining to such confidential information. 1CM, its agents and employees are hereby released from any and all liabilities, responsibilities, damages, claims and expenses arising from the release of information as authorized above. Reasons for releasing a Patient’s record include, but are not limited to, insurance company(s), their agents or other third
party payor and/or government or social service agencies which may or will pay for any part of the medical/hospital expenses incurred or authorized by representatives of 1CM, as mandated by law, or to alternate care providers, including community agencies and services, as ordered by Patient’s physician or as requested by Patient or Patient’s family for post-hospital care.
PATIENT ACKNOWLEDGES AND AGREES THAT PATIENT’S RECORDS WILL BE AVAILABLE TO ALL 1CM AFFILIATED ENTITIES AND PROVIDERS, AND TO NON-1CM AFFILIATED REFERRING PROVIDERS IN COMPLIANCE WITH THE PROVISIONS OF MEANINGFUL USE.
Patient also agrees, in order for 1CM to service accounts or to collect liabilities owed, to receive contact by telephone at any telephone number associated with their record, including wireless telephone numbers, which could result in charges to Patient. 1CM or its agents may also contact Patient by sending text messages or emails, using any email address Patient provides. Methods of contact may include using pre-recorded/artificial
voice messages and/or use of an automatic dialing device, as applicable.
8. Release of Medical Records
Patient agrees that if patient requests medical records from 1CM, Patient is responsible for the total cost to release his/her medical records. 1CM may cover the costs associated with releasing medical records from an outside Covered Entity when 1CM requests the medical records on Patient’s behalf. In the event that 1CM requests the release of Patient’s medical records from an outside Covered Entity on Patient’s behalf and chooses not to cover all or any of the associated costs, Patient agrees that he/she is responsible for the total cost of releasing his/her medical records.
8. Consent Timeframe and Applicability
The above agreements are applicable to all inpatient or outpatient services provided by 1CM and all ambulatory or physician office-based services and are valid for a term of one (1) year from the date of signature below.
Validity of Form
Patient acknowledges that a copy or an electronic version of this document may be used in place of and is as valid as the original. The patient confirms that he/she has read and understood and accepted the terms of this document and he/she is the patient, the patient’s legal representative or is duly authorized by the patient as the patient’s general agent to execute the above and accept its terms.
