Notice of Privacy Practices

We ask each patient to review and sign these forms before their first visit.

ASSIGNMENT OF BENEFITS AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I hereby certify that the insurance information I have provided is accurate, complete, and current, and that I have disclosed all applicable insurance coverage. I assign and authorize direct payment of all authorized benefits payable under Medicare, Medicaid, and/or any private insurance plan or other health benefit program to the provider or supplier for services rendered to me by that provider or supplier. I further authorize my provider to file claims, appeals, and grievance requests on my behalf for any denial of payment and/or adverse benefit determination related to services and care provided. If my health insurance plan does not pay my provider directly, I agree to promptly forward to my provider any health insurance payments I receive for services rendered by my provider and affiliated healthcare professionals. I authorize my provider, and any holder of medical or billing information about me or the patient named below, to release to my health insurance carrier, governmental payer, or authorized third party any information necessary to determine eligibility for benefits, obtain payment for services rendered, process claims, or support appeals and utilization review activities. I understand that if my provider is not participating in my insurance plan’s network, or if I am a self-pay patient, this assignment of benefits may not apply and I may remain financially responsible for payment of services.

I acknowledge that I am responsible for any deductibles, co-payments, co-insurance amounts, non-covered services, or balances not paid by my insurance carrier.

CONSENT TO CALL, EMAIL & TEXT COMMUNICATIONS

I understand and agree that my healthcare provider and its representatives may contact me using automated telephone calls, prerecorded voice messages, emails, and/or text messages sent to my landline telephone number and/or mobile device.

These communications may include, but are not limited to:

  • Appointment reminders and scheduling information

  • Preventive care reminders

  • Test and laboratory results

  • Treatment recommendations and follow-up care instructions

  • Prescription notifications

  • Billing statements, outstanding balances, and payment reminders

  • Patient satisfaction surveys

  • Other healthcare-related communications from my provider

I understand that standard message and data rates from my mobile carrier may apply.

I acknowledge that electronic communications, including email and text messaging, may not always be secure and may carry some risk of unauthorized access or disclosure.

I understand that I may opt out of receiving certain or all non-emergency communications at any time by:

  • Notifying my provider's staff

  • Updating my communication preferences through the Patient Portal under "My Profile"

  • Or contacting the Privacy Officer at: contact@bloomwinchester.com

I understand that opting out of communications may affect my ability to receive important information regarding my healthcare, appointments, billing, or treatment.

GUARANTEE OF PAYMENT & PRE-CERTIFICATION

In consideration of the medical services provided by my healthcare provider, I acknowledge and agree that I am financially responsible for all charges incurred for services rendered that are not covered by my health insurance plan, or for which I am otherwise responsible under the terms of my insurance coverage, including but not limited to deductibles, co-payments, co-insurance amounts, and non-covered services.

I agree to promptly pay all balances due for services provided. To the extent permitted by applicable law, I further agree to reimburse my provider for any reasonable costs, expenses, collection fees, and attorney's fees incurred in the collection of unpaid balances owed on my account.

If my insurance plan requires pre-certification, prior authorization, referral approval, or other authorization for services rendered, I understand that it is my responsibility to obtain and maintain such authorization in accordance with my insurance plan's requirements and provisions. I understand that failure to obtain required authorization may result in a reduction or denial of insurance benefits, and I agree that I will remain fully responsible for payment of any balances due as a result of such denial or reduction in coverage.

I acknowledge that verification of insurance benefits by my provider is not a guarantee of payment by my insurance carrier.

HIPAA PRIVACY

I understand that my provider's Notice of Privacy Practices is available at www.bloomwinchester.com and that I may request a paper copy at any time from my provider's reception desk.

I hereby acknowledge that I have received, reviewed, or been offered access to my provider's Financial Policy and Notice of Privacy Practices.

I understand and agree to the terms of my provider's Financial Policy and consent to the use and disclosure of my protected health information as described in the Notice of Privacy Practices, including the sharing of my information through applicable Health Information Exchange systems, as permitted by law.

I further consent to evaluation, treatment, and healthcare services provided by my provider and affiliated healthcare professionals.

I understand that this acknowledgment, consent to treatment, and assignment of benefits shall apply to and remain in effect for future visits, treatments, and appointments with all affiliated providers and entities associated with the practice, unless revoked in writing where permitted by law.

MEDICATION HISTORY AUTHORITY

I authorize my healthcare provider, its staff, and its business associates to obtain and review my medication history from pharmacies, pharmacy benefit managers, health plans, and other healthcare providers or sources as permitted by law. I understand that this medication history may include information about prescriptions I have filled, medications currently prescribed to me, and other related prescription benefit information.

I understand that this information will be used to support my treatment, improve the accuracy of my medication records, help identify potential medication interactions or safety concerns, and assist with prescription-related care decisions.

I understand that this authorization is voluntary and that I may decline to provide it; however, if I do not authorize access to my medication history, my provider may have less complete information available when making treatment decisions.

If permitted by applicable law, this authorization will remain in effect unless and until I revoke it in writing.

RELEASE OF INFORMATION

I, Patient First Name Patient Last Name, authorize Patient's Usual Provider to disclose and release to my insurance carrier(s), including Medicare, Medicaid, Medigap/Supplemental benefits providers, and private insurers, as applicable, any medical and treatment information needed for payment purposes for services rendered. I authorize use of this form for the release of information needed to process claims to all my insurance carrier(s) and its authorized agents. I authorize my provider/practice to act as my agent in helping obtain payment from my insurance companies.