X

HIPAA Release & Consent:

I, the maternity patient, hereby authorize Earthside Billing and its employees, agents, and representatives (“Earthside”) to request, access, receive, and review my medical records and protected health information (“PHI”), including but not limited to information, documents, and/or records regarding my health status, treatments, medications, provisions of health care, prenatal care, delivery care, postpartum care, health care billing, and/or payment history, obtained from and/or provided by my health care providers, professionals, and facilities, including but not limited to my midwife(s), doula(s), physician(s), birth center(s), hospital(s), and parallel prenatal care provider(s), as needed by Earthside to prepare, process, and submit claims and appeals on my behalf.

I hereby authorize and release Earthside Billing and its employees, agents, and representatives (“Earthside”) to prepare, transmit, process, and submit on my behalf claims, appeals, and benefit verifications to my private insurance company, or other insurance, government, or employee healthcare plan, provider, organization, or agency, and its agents, employees, and representatives, which may provide coverage and/or benefits to me (“Payer”). I hereby authorize and consent to Earthside releasing, using, communicating, transmitting, sharing, and disclosing all or part of my medical records and PHI to my Payer(s) as necessary to verify, authorize, submit, and process insurance claims and appeals on my behalf consistent with Federal HIPAA regulations. I understand that no other use of my PHI is needed or authorized.

This authorization shall remain in effect for twenty-four (24) months from the date of execution. I understand that I have the right to revoke this authorization, in writing, at any time, except to the extent that Earthside has acted in reliance upon it, by sending written notification via email to alisha@earthsidebilling.com or via fax to (408) 757-0984. I understand that no other use of my PHI is needed or authorized other than for purposes of Payer billing, payment, and reimbursement. I understand that I as the signer am entitled to a copy of this HIPAA RELEASE & CONSENT form by sending written request to via email to alisha@earthsidebilling.com or via fax to (408) 757-0984.

I AUTHORIZE EARTHSIDE BILLING TO RECEIVE AND RELEASE ANY INFORMATION NECESSARY TO PREPARE, PROCESS, AND SUBMIT MY INSURANCE CLAIMS AND APPEALS ON MY BEHALF. I CONSENT TO EARTHSIDE BILLING'S USE AND DISCLOSURE OF MY HEALTH INFORMATION FOR PURPOSES OF BILLING, PAYMENT, AND REIMBURSEMENT.

I ACKNOWLEDGE THAT I HAVE READ THIS HIPAA RELEASE & CONSENT, AND I UNDERSTAND ITS CONTENTS. I ACKNOWLEDGE THAT I AM THE MATERNITY PATIENT, OR PERSON DULY AUTHORIZED EITHER BY THE MATERNITY PATIENT OR OTHERWISE, SIGNING AND CONSENTING TO THIS RELEASE AND ACCEPTING ITS TERMS.

I acknowledge that checking the checkbox below, I am signing this HIPAA RELEASE & CONSENT electronically. I understand that this Authorization may be executed using an electronic signature, and I understand that any electronic signature shall be deemed an original signature for purposes of this Authorization, with such electronic signature having the same legal effect as an original signature.

DISCLAIMER:

EarthSide Billing, Inc. provides accurate information to the best of our ability, however, we do often rely on the representative for the insurance to interpret and provide details when the policy booklet does not adequately define benefit coverage. EarthSide Billing Inc. does not guarantee accuracy of details provided by the insurance nor can we guarantee claim payment or reimbursement. EarthSide Billing, Inc. has a no-refund policy once we have started working on your file. All sales are final.

Verification of Benefits and Patient Responsibility Amounts provided by Earthside Billing are not a guarantee of payment or reimbursement. Rather, Verification of Benefits and Patient Responsibility Amounts provided are estimates of cost and do not replace any contracts or amounts requested by your provider.

Authorizations and Claim Submissions are not a guarantee of payment or reimbursement. Claim payment and/or reimbursement are subject to your specific plan benefit and the network status of your provider. Earthside Billing does not guarantee nor control the amount paid by your insurance company or health plan provider. Depending on your plan, the claim may be processed to your plan deductible and/or out-of-pocket.

Submissions take a minimum of twenty-one (21) business days to receive a response from your insurance company or health plan provider. Please make sure you have allotted the correct amount time for authorization, submission, response, and appeal.