Healthcare Blue Cross Agreement

HEALTHCARE BLUE CROSS AGREEMENT

Patient Name:    Date of Birth:    Patient ID (if any): 

Patient Information

Insurance Information

Medical History (to assist treatment and claims)

Agreement; Assignment of Benefits; Release

By signing below, Patient authorizes and directs any health plan, including Blue Cross plans, to pay benefits directly to the treating provider for services rendered. Patient expressly assigns to Provider all rights and benefits payable under applicable insurance policies for services provided by Provider. Patient certifies that information provided on this form is true and correct to the best of Patient's knowledge.

Patient authorizes Provider to release medical records, billing information, and other protected health information as necessary to adjudicate claims and receive payment from Patient's insurer. This authorization includes release of records to Blue Cross plan administrators, reviewers, billing agents, and their designees for claims processing and appeals.

Assignment of Benefits:   I agree to assign benefits and direct payment to Provider.

Authorization to Release Information & Authorization Expiration

Patient authorizes disclosure of protected health information (PHI) to insurance carriers, their agents, and other entities as necessary for treatment, payment, and healthcare operations. Patient understands that information released may include, if applicable, diagnosis, treatment records, and summary of services rendered.

Patient may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance upon it. Unless revoked, this authorization expires on the date specified above and, if no date is specified, one year from the date of signature.

HIPAA Privacy Acknowledgment

Patient acknowledges receipt of the Provider's Notice of Privacy Practices and understands that protected health information may be used and disclosed for the purposes described in that notice. Patient authorizes the release and disclosure of information as necessary for claims processing, care coordination, and quality assurance.

Acknowledgment of Notice of Privacy Practices:   I acknowledge that I have received or been offered the Provider's Notice of Privacy Practices.

Financial Responsibility; Payment Terms

Patient understands that submission of a claim to Blue Cross or another insurer does not relieve Patient of financial responsibility. Patient is responsible for copayments, coinsurance, deductibles, and any charges not covered by insurance. Patient agrees to pay Provider for services that insurers deny, that exceed coverage, or that are not a covered benefit.

Financial Responsibility Agreement:   I accept financial responsibility for charges not paid by my insurer.

Consent to Treatment

Patient consents to such medical evaluation and treatment as deemed necessary by Provider. Patient acknowledges that all procedures, risks, benefits, and alternatives have been explained, and that Patient has had an opportunity to ask questions. Patient has the right to withdraw consent at any time by notifying Provider in writing.

Consent to Treatment:   I consent to evaluation and treatment by Provider.

Dispute Resolution; Miscellaneous

Any dispute arising from this Agreement will be governed by the laws of the state where services are rendered, without regard to conflict-of-law principles. If any provision of this Agreement is determined to be invalid or unenforceable, the remaining provisions will remain in full force and effect.

Certifications and Signature

By signing below, Patient certifies that Patient is the subscriber or an authorized representative of the subscriber named above, that the information provided is accurate, and that Patient has read and understands the terms of this Agreement including assignment of benefits, authorization for release of information, HIPAA acknowledgment, and financial responsibility.

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