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.