In order to be in compliance with Health and Human Service Requirements, we must ask the following questions:
PLEASE CAREFULLY REVIEW AND SIGN AT THE BOTTOM OF THE PAGE TO ACCEPT.
Insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a certain percentage of the charge. It is your sole responsibility to pay any deductible amount, co-insurance, or other balance not paid for by your insurance.
You are responsible for knowing if your insurance policy requires a referral to see the provider, or if there are special requirements for your insurance policy. To make your visit as easy as possible, we must have this information before you can be seen by the doctor. There may be certain routine services performed during your visit or upcoming visits that may or may not be covered. It is your responsibility to contact your insurance company prior to any procedure to see if they are covered.
I, the undersigned, consent to treatment necessary for my care. I hereby authorize release of any or all medical records to the referring physicians, my insurance carriers/Medicare/Medicaid and those involved in payment of my account. I understand that payment of charges incurred in the office is due at the time of service. I also understand that charges not covered by insurance remain my responsibility and assign insurance benefits to MiBella Gynecology, LLC. I agree to assume the financial responsibility for services not reimbursed under my insurance plan.
I, the undersigned, agree that if my account becomes past due, that my account will be turned over to a collections agency. All charges incurred to collect payment including collection agency fee, attorney fees and/or court costs, if such be necessary will be my responsibility and I hereby waive all rights to exemption under the Constitution of the State of Alabama.
Returned Checks: There is a fee of $30 that will be charged on your account for any checks that are returned by the bank. Any checks that are returned will void any previous payment arrangements and the account balance will be due in full immediately. You will be unable to write checks in the future.
Cash Services (Services that are not billed to insurance): PAYMENT/PRE-PAYMENT FOR ALL CASH SERVICES ARE NON-REFUNDABLE. In the event that you are unable to complete a pre-paid treatment program/regimen, you will be allowed up to one calendar year (from the date of your first missed appointment), to complete it as prescribed/recommended by Dr. Cowan. They may be transferred towards other cash services.
By executing this agreement, you are agreeing to pay for all services that are rendered. Your signature below indicates that you agree to all the terms and conditions contained herein.
I further agree that a photocopy of this original shall be valid as an original.
To better serve our patients and ensure the availability of appointments, the following policy is necessary: There will be a $40 charge if you fail to cancel your scheduled appointment (24) hours prior to your appointment time. If your appointment is on a Monday, please call the Friday before your scheduled appointment to cancel or reschedule to avoid the cancellation fee.
For frequent missed appointments, we may require a non-refundable and non-transferable deposit for all future appointments. Your credit card on file will be billed $40 on the day of your visit if you fail to cancel your appointment 24 hours prior to the scheduled time. In the event, no credit card is on file, you will be billed the $40 cancellation fee, which must be paid prior to any future appointments.
If you are more than 15 minutes late for your appointment it is equivalent to a No-Show. You will be charged or billed $40 and will have to reschedule your appointment.
A (48) hour notice is required for all surgery cancellations. Cancellations with less than (48) hour notice, will be charged a fee of $50.
Other Fees: There is a $25 charge for all forms, letters, FMLA forms, etc. and a $25 plus for copying of medical records.
My protected health information may be released to someone(s) that I give permission. Do you wish to designate someone other than your doctor to receive/request your protected health information? This person could be spouse, child, or caregiver, etc. I understand that I have the right to change the designee at any time by written request. Patients age 18 and older must sign for information to be released.
If yes, please complete the following:
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. (www.hhs.gov)
We have adopted the following policies:
I hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward. I have seen the privacy notice posted in the waiting room of MiBella Gynecology and a copy has been made available to me.
Preventive Care, also known as a Well Woman Exam or Checkup, includes an age appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions and the ordering of laboratory/ diagnostic procedures. Preventive Care Services may or may not have a copayment and it is the individuals' responsibility to know their coverage guidelines.
Important Note:If an abnormality is encountered or a pre-existing problem is addressed in the process of performing the Preventive Care Services, an additional evaluation and management (office visit and/or outpatient visit) may be necessary (and billable) in addition to the Preventive Care Service. In this instance, the applicable office visit and/or outpatient visit co-pay, co-insurance or deductible amount may be applicable and due at the time of service.
I, the undersigned, give MiBella Gynecology, LLC dba MiBella Wellness Center, Dr. Mia Cowan, its employees and/or agents consent to contact me at any/all phone numbers associated with my account, including wireless phone numbers, which could result in charges to you, for the purpose of treatment, appointment reminders, insurance, collections and/or payment. We may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, if applicable.
From time to time, Dr. Cowan's office will send out special announcement, informational newsletters and upcoming specials/promotions. These, as well as appointment reminders, are generally sent out via text and/or email. I understand I can opt-out at any time. Once you opt out, you will be removed from our text and email privileges.
MiBella strives to provide the highest quality service to all of our patients. However, we cannot do it alone. We need your assistance in making that possible. Please take note of the following things
NEW PATIENTS: Fill out form below completely. Thank you.
EXISTING PATIENTS: Complete applicable changes/updates.
Covid-19 is a pandemic. If you are experiencing signs or symptoms, have traveled out of the country in the last 14 days, have been around someone who has traveled out of the country in the last 14 days, or have been exposed to someone diagnosed with COVID-19 or the flu please reschedule your appointment.
At MiBella, we are doing everything we can to keep our patients and staff safe. Let us know if you have any questions.
Signs and symptoms of COVID-19 may appear 2 to 14 days after exposure and can include the symptoms below.If are you presently experiencing:
I will immediately notify MiBella Wellness Center, if I test positive for COVID-19 within 3 weeks of my in-office visit.
Do I have to leave my credit card information to be a patient at this practice?
Yes. This is our policy, and it is a growing trend in the healthcare industry. Insurance reimbursements are declining and there has been a large increase in patient deductibles. The amount of time and effort to collect payments that will be saved will allow our office to focus more on patient care. We have decided to focus on becoming more efficient in our billing and collections processes instead.
How much and when will money be taken from my account?
The insurance companies on average take approximately 2-3 weeks to process submitted claims. Whatever the allowed amount is, your copay, coinsurance, and deductible are taken into consideration. It simply depends on your individual policy what you may owe. Once the insurance explanation of benefits is received and posted to your account, you will be sent a statement showing your portion. You will have 15 days to send an alternative form of payment if you prefer. If no alternative payment is received, your patient financial responsibility will be processed.
How do you safeguard the credit information you keep on file?
We use the same methods to guard your credit card information as we do for your medical information. The card information is securely protected by the credit card processing component of our PCI and HIPAA compliant practice management system. This system stores the card information for future transactions using the same sort of technology that any online retailer would. We can't see the card number - only the last four numbers, giving us no way to use the card outside of the billing system. There is no way to export the card information out of our system. The only way to use it is to process a payment in our practice management system.
What are the benefits?
It saves you time and eliminates the need to write checks, buy stamps or worry about delays in the mail. It also drives our administrative costs down because our staff sends out fewer statements and spends less time taking credit card information over the phone or entering it from the billing slips sent in the mail, which are less secure methods than us storing the information. The extra time the staff has can now be spent on directly helping the patients, either over the phone, with insurance claims or in person.
I always pay my bills on time.
Why do I have to do this? The entire billing process is time-consuming and wasteful, and the few patients that we do have to send to a collection agency end up costing a lot of money. Reducing unnecessary costs is essential to allowing us to continue to be your provider. Nothing is changing about how much you end up paying.
What if there is a payment discrepancy or I have other payment questions?
Please contact our office directly to settle payment discrepancies or for other payment questions. This policy in no way compromises your ability to dispute a charge or questions your insurance company's explanation of benefits.
Will I still receive a receipt/invoice bill by mail?
Yes. You will receive a paid receipt/invoice for each transaction by mail or email based on your preference.
What time frame should my appointment be cancelled to avoid a no-show/cancellation fee?
All appointments must be cancelled or rescheduled within 48 business hours Monday - Thursday 8:30 am - 4:00 pm. Patients are welcome to call, leave a voicemail, or send a text, email, or portal message.
MiBella Wellness Center has implemented a new credit card policy to allow smooth transactions and billing for your visits. It Is our policy to collect all co-payments/coinsurance and balance amounts at the time of service. Additionally, we require a credit or debit card from you for any future balance you may be responsible for from your visit(s). A statement will be sent to you via email and text around the 1st and the 15th of each month. At least (15) calendar days before your credit card is charged (if applicable), you will receive an email notification informing you of the balance that is your responsibility to pay. AFTER FIFTEEN (15) CALENDAR DAYS, YOU WILL BE CHARGED THE REMAINING BALANCE ON YOUR ACCOUNT FOR THIS DATE OF SERVICE.
Please provide the front desk staff with your photo ID, your insurance card, and your method of payment. Your information will be on file and kept secure while you are an active patient or until we have been informed by you that you have transferred your care to a new provider. We only have visibility to the encrypted token and the authorization per this agreement form with you.
We obtain the right to charge your card for all charges incurred for any services rendered that were not covered by your insurance company, for no-show appointment fees, and for late cancellation/arrival fees. Such action will only be processed if you fail to comply with our office patient policies and requirements. Upon your request, a receipt may be provided, in-person or by e-mail after any charge has been made to your provided payment method.
No-Show/Cancellation/Late arrival fees are charged on the same day. Please reschedule/cancel appointments within 48 business hours. Business hours are Monday - Thursday from 8:30 am to 4:00 pm.
· Gynecology office/telehealth visits - $40
· Ultrasound visits - $100
· Cash Services - $100
· Surgery - $200
I authorize MiBella Wellness Center to charge my credit card for fees associated with services not covered by insurance, no-show appointments, and late cancellation. I understand that the fees are based on the visit types and for failure to comply with patient requirements. I also understand that it is my financial responsibility to call my insurance company for an explanation of services not covered by insurance, health savings benefits, as well as medical financing care cards.
This authorization will remain in effect until you cancel this authorization. To cancel this service, a written notification must be provided to our office. Please note that if you have an outstanding balance, your card cannot be removed without providing a new credit card for payment.
Please acknowledge that you have read and understand MiBella Wellness Center new credit card policy: