Authorization & Consent to Treatment

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

CONSENT TO TREATMENT

I voluntarily consent to the rendering of such care and treatment as my providers, in their professional judgment, deem necessary; however, I may refuse any treatment or procedure at any time.

I acknowledge that neither my provider nor any of her staff have made any guarantee or promise as to the results that l will obtain. All treatment adheres strictly to Health Insurance Portability and Accountability Act (HIPAA) compliance guidelines to ensure my data is secured and protected.

CONSENT TO CALL, EMAIL, AND TEXT

I understand and agree that my provider may contact me using automated calls, emails and/or text messaging sent to my landline and/or mobile device. These communications may notify me of preventative care, test results, treatment recommendations, outstanding balances, or any other 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 all such communications from my provider by notifying my provider's staff or by visiting "My Profile" on my Patient Portal. I understand that opting out of communications may affect my ability to receive important information regarding my healthcare, appointments, billing, or treatment.

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. This form will be signed by the patient's parent or legal guardian if the patient is a minor or otherwise not competent.

*Note: If you do not want to participate in Health Information Exchange (HIE), it is your responsibility to follow the instructions outlined on the my provider HIE Opt-Out Request Form and/or contact the HIE directly.

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.

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.

FINANCIAL POLICY

We are pleased that you have chosen us as your healthcare provider. To avoid any misunderstandings and ensure timely payment for services, it is important that you understand your financial responsibilities with respect to your health care. We require all patients to sign both our Financial Policy Form and Authorization and Consent To Treatment Form before receiving medical services. That form confirms that you understand that the healthcare services provided are necessary and appropriate and explains your financial responsibility with respect to services received as set forth in this policy.

PATIENT RESPONSIBILITY

Patients or their legal representative are ultimately responsible for all charges for services provided. When the insurance plan provides immediate information regarding patient responsibility, we may request payment for your share when you schedule and/or when you present for your appointment. As a convenience to you, we can save a credit card on file to settle your account when you check in or out. You may receive an estimate for your patient

responsibility prior to or at the time of your service. If there is a difference in the estimated patient responsibility, we will send you a statement for any balance due. If a credit balance results after insurance pays, we will apply the credit to any open balance on your account. If there are no open balances, we will issue a refund.

If you have an Annual Gynecology Visit or Physical/Preventative Exam, but need or request additional services, we may bill you for those additional services. All services for patients who are minors will be billed to the custodial parent or legal guardian. If you have a large balance, a payment plan may be available.

INSURANCE

We ask all patients to provide their insurance card (if applicable) and proof of identification (such as a photo ID or driver's license) at every visit. If you do not provide current proof of insurance, you may be billed as an uninsured patient (i.e., self-pay). We accept assignment of benefits for many third party carriers, so in most cases, we will submit charges for services rendered to your insurance carrier. You are expected to pay the entire amount determined by your insurance to be the patient's responsibility. Keep in mind that our fees are for provider services only; you may receive additional bills from laboratory, radiology or other diagnostic related providers.

You are responsible for understanding the limitations of your insurance policy, including:

If a referral or authorization is necessary for office visits. (If it is required and you do not have the appropriate referral or authorization, you may be billed as an uninsured patient).

Prescribed testing (lab, radiology, etc.) is covered under your insurance policy, though the management of payment for services performed at external offices will be determined by the external office staff and the patient. (If you choose to have non-covered testing, Bloom Women’s Health offers in-house rates for lab bloodwork.)

NO SURPRISES ACT / GOOD FAITH ESTIMATE OF CHARGES

If you do not have insurance or are not using insurance to pay for your care, you have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost. Under the NO SURPRISES ACT, health care providers must give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

If you would like a Good Faith Estimate, make sure your health care provider gives you a Good Faith Estimate in writing at least one (1) business day before your medical service or item.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-888-774-8428.

YOUR RESPONSIBILITIES

Outstanding Balances. After your visit, we will send you a statement for any outstanding balances. We send out statements when the balance becomes the patient's responsibility.

All outstanding balances are due on receipt. If you come for another visit and have an outstanding balance, we will request payment for both the new visit and your outstanding balance. Your outstanding balances can be paid conveniently via our patient portal.

We may add a finance charge of 1.33% of your outstanding account balance every month if you do not pay your account in full.

If you have an outstanding balance for more than ninety (90) days, you may be referred to an outside collection agency and charged a collection fee of 23% of the balance owed, or whatever amount is permitted by applicable state law, in addition to the balance owed. In addition, if you have unpaid delinquent accounts, we may discharge you as a patient and/or you may not be allowed to schedule any additional services unless special arrangements have been made.

No-shows. If you miss your appointment, you may be charged a $25.00 fee for a missed appointment. This fee will need to be paid before you are allowed to schedule another appointment. This fee cannot be billed to insurance.

I hereby acknowledge that I have received and agree to the terms of my provider's Financial Policy. This form applies and extends to subsequent visits and appointments.

GUARANTEE OF PAYMENT AND PRE-CERTIFICATION 

In consideration of the services provided by my provider, I agree that I am responsible for all charges for services I receive that are not covered by my health insurance plan or for which I am responsible for payment under my health insurance plan, 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.

RELEASE OF BILLING INFORMATION 

I authorize my 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. 

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 my right to receive payment of authorized benefits under Medicare, Medicaid, and/or any of my insurance carriers to the provider or supplier of any services furnished 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.