I hereby give my consent to Carecube to discuss my Protected Health Information (PHI) with the following person:
By signing this form, I authorize my insurance benefits to be paid directly to the physician and I am financially responsible for all changes. I hereby consent to the release and re-disclosure of my medical records to enable or facilitate the collection, verification or settlement of my account for any amounts due from me or any third-party payer, health-maintenance organization insurer or other health benefit plan, in accordance with the HIPPA Guidelines. A copy of the HIPPA Guidelines is available at our front desk. This consent applies to CareCube, or any of its affiliates or agent's lenders, or third party services acting for CareCube, or any of its affiliates. I agree to promptly pay for services rendered for me or the patient named above. If I fail to meet my financial commitment to CareCube, and it becomes necessary to take action to collect the amount owed on my account, I agree to pay all costs and expenses incurred in the collection of my account, including attorney and collection agency fees. I further agree to pay for any missed appointments of which I did not notify the medical office within 48 hours of my scheduled appointment. I authorize CareCube to test my blood for hepatitis and/or the AIDS virus, if in their opinion, and an employee if they have suffered an exposure incident as a result of my treatment, as defined by the Occupational Safety and Health Administration. I authorize CareCube to obtain records from other sources as may be necessary for the diagnosis or treatment of my condition(s). By signing below, I acknowledge that I have been provided a copy of the HIPPA Guidelines to read.
Having the correct insurance information at all times is very important to us. Most insurance companies have a timely filing period of 60 days. If we bill the wrong insurance, it could take up to 60 days to get a denial from them. So please, any time you have any new information, let us know immediately.
By signing this form, I am aware that all insurance information I have provided to CareCube is true and up to date. I am responsible for following all rules and regulations that are implemented by the insurance carrier which I am covered by. This includes obtaining a proper referral form/authorization for my visits and diagnostic procedures, bringing the referral form/card or referral number/authorization for my visits or diagnostic procedures, bringing the referral form/card or referral number/authorization number with me to my appointments, and any other rules I must follow with my insurance carrier. If my insurance does not cover my visits or diagnostic procedures for any reason, I am responsible for payment within 30 days of the denial. I understand that there will be a billing service charge of $20.00 for EACH statement mailed to me. I also understand the financial policy which states that if I do not pay the balance in full within 60 days of the date of the statement, CareCube will place this balance on my credit card report under my social security number and driver's license number (if applicable) and it will stay there until the balance is paid in full, and removed at that time.