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Cohosh Client Information
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    Please select an answer for each of the four rows (you may have to scroll down). For more information about our services, please visit the Services & Fees page of our website: https://cohoshbilling.com/services-and-fees
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    AUTHORIZATION TO RELEASE INFORMATION I hereby authorize my midwife and/or birth center and Cohosh to: (1) process insurance claims generated in the course of examination or treatment; and (2) release any information necessary to my health insurance plan (or its administrator) regarding care I have received. I understand this information is protected by law and will be kept confidential. VERIFICATION OF BENEFITS CONSENT The information I have provided to Cohosh is true to the best of my knowledge.  I acknowledge that a verbal quote of benefits from my health insurance provider is not a guarantee of payment, which is determined according to the provisions of my health insurance coverage at the time services are rendered. I understand that I am responsible for payment of applicable deductible, coinsurance, copayment, and premium amounts, as well as any charges not covered by my health insurance. I understand that the verification of benefits report is provided as a financial planning tool, and that the information contained therein is not considered binding by my health insurance provider, midwife, or birth center. I understand that Cohosh is not responsible for incorrect information provided by the representatives of my health insurance provider. I acknowledge that Cohosh specifically disclaims liability for incidental or consequential damages and assumes or undertakes no responsibility or liability for any loss or damage suffered by any person as a result of the use or misuse of information included in the verification of benefits report. I acknowledge that in the case of gross negligence or willful misconduct, the liability of Cohosh to any client seeking verification of benefits services is limited to the cost of verification of benefits ($45.00) under this agreement. APPEAL, CLAIM, AND INVOICE PREPARATION AND SUBMISSION CONSENT I authorize, to the full extent permissible under law and under any applicable health insurance policy and/or healthcare benefit plan, Cohosh to act as my authorized representative. As such, Cohosh is granted: (1) the right and ability to submit claims to the health insurance plan (or its administrator) listed on my current insurance card of which I have provided a copy; (2) the right and ability to act on my behalf in connection with any claim, right, or cause in action that I may have under such health insurance policy and/or healthcare benefit plan; and (3) the right and ability to act on my behalf to pursue such claim, right, or cause of action in connection with said health insurance policy and/or healthcare benefit plan, including, but not limited to, the right to act on my behalf in respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. §2560.503-1(b)(4), with respect to any healthcare expense incurred as a result of the services I received from my midwife and/or birth center, to the extent permissible under the law, and to claim on my behalf such benefits, claims, reimbursements, and other applicable remedies, including fines. I acknowledge that submission of an appeal, claim, or invoice is not a guarantee of payment, which is determined according to the provisions of my health insurance coverage at the time services are rendered. I understand that I am responsible for payment of applicable deductible, coinsurance, copayment, and premium amounts, as well as any charges not covered by my health insurance. I authorize the irrevocable assignment and transfer to my midwife and/or birth center of all applicable health insurance benefits to which I am entitled and/or my dependents are entitled. I authorize my health insurance plan (or its administrator) to make payments directly to my midwife and/or birth center. I understand that Cohosh specifically disclaims liability for incidental or consequential damages and assumes or undertakes no responsibility or liability for any loss or damage suffered by any person as a result of the adjudication of claims submitted by Cohosh on my behalf. I acknowledge that in the case of gross negligence or willful misconduct, the liability of Cohosh to any client seeking claim preparation and submission services is limited to the cost of claim preparation and submission ($90.00 per claim) under this agreement. This consent will remain in effect until revoked by me in writing. A photocopy or electronic transmission of this consent shall be as effective and valid as the original.
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