Three Birds Billing

 HIPAA RELEASE & CONSENT:

I, the maternity patient, hereby authorize Three Birds Billing 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 Three Birds Billing to prepare, process, and submit claims and appeals on my behalf.

I hereby authorize and release Three Birds Billing and its employees, agents, and representatives (“Three Birds Billing”) 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 Three Birds Billing 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 Three Birds Billing has acted in reliance upon it, by sending written notification via email to threebirdsbilling@gmail.com. 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 threebirdsbilling@gmail.com.

I AUTHORIZE Three Birds Billing TO RECEIVE AND RELEASE ANY INFORMATION NECESSARY TO PREPARE, PROCESS, AND SUBMIT MY INSURANCE CLAIMS AND APPEALS ON MY BEHALF. I CONSENT TO Three Birds 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, 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: Three Birds Billing does not guarantee claim payment or reimbursement.

Verification of Benefits and Patient Responsibility Amounts provided by Three Birds 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. Three Birds 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 of time for authorization, submission, response, and appeal.