Healthcare BOB Agreement

HEALTHCARE BOB AGREEMENT

This Healthcare BOB Agreement ("Agreement") documents the patient's authorization for coordination of benefits, assignment of insurance benefits, release of medical information, and acceptance of financial responsibility as described below. Patient Name: Date of Birth:

1. Patient Information

Gender: Male Female Other

2. Insurance Information

Is patient the primary subscriber? Yes No

3. Medical History — Current Status

Chronic Conditions (check all that apply):
Diabetes Hypertension Heart disease None listed

4. Authorization: Assignment of Benefits & Billing (BOB)

Assignment of Benefits: I hereby authorize and direct my health insurer, third-party payers, and any other responsible parties to pay directly to the providing healthcare facility and its billing agent all benefits otherwise payable to me for services rendered. This assignment includes payments for professional services, facility charges, supplies, diagnostics, and any related services billed on my behalf.

Coordination of Benefits: I authorize the provider to obtain and exchange information necessary to coordinate benefits between insurers, including secondary and tertiary carriers, and to bill other responsible parties. I consent to the provider submitting claims and appeals on my behalf and to receiving insurance payments sent directly to the provider.

Authorization to Balance Bill: If insurer payments do not reimburse the full amount billed, I accept financial responsibility for any remaining patient balance, including co-payments, deductibles, co-insurance, and balances not covered by insurance. I authorize the provider to bill me for such balances and to pursue collection actions if necessary.

Assignment Opt-Out: If I do not wish to assign benefits to the provider, I understand I must indicate below and will remain financially responsible for payment at the time of service.
I do not assign benefits to the provider and will personally accept full payment responsibility at the time of service.

5. Release of Information & HIPAA Acknowledgment

I authorize the release of my medical information, including protected health information, to my insurance carriers, billing agents, healthcare providers involved in my care, and other entities as necessary for claims processing, payment, and healthcare operations. I acknowledge receipt of the provider's Notice of Privacy Practices and understand my rights regarding protected health information.

Purpose and Duration: This authorization is valid for the purposes described above and remains in effect until the earlier of the date indicated in the expiration field below or my written revocation. I understand that revocation will not affect disclosures made prior to receipt of revocation. Expiration Date:

6. Consent to Treatment & Acknowledgements

Consent to Treatment: I consent to diagnostic and therapeutic procedures and treatment as deemed necessary by my treating provider. The provider has explained the nature of proposed care, potential benefits, common risks, and reasonable alternatives. I have had the opportunity to ask questions and understand my right to decline treatment.

Right to Withdraw: I may withdraw this authorization at any time by providing written notice to the provider. Withdrawal will not affect actions already taken in reliance on this authorization prior to receipt of the revocation.

7. Financial Terms and Certification

Billing Practices: I understand that the provider may bill me for services not covered or only partially covered by my insurer, and that I remain responsible for timely payment of any patient responsibility amount. I acknowledge that payments received from insurers applied to my account will be credited accordingly and that adjustments may occur if insurers later modify payments.

Certification: I certify that the information I have provided on this Agreement is true and correct to the best of my knowledge. I authorize the release and use of the information described above for the purpose of claims submission, coordination of benefits, and payment collection.

8. Additional Authorizations & Notices

Relationship to Patient:

By signing below, I acknowledge that I have read and understand this Agreement, that I have had the opportunity to ask questions, and that I consent to the terms herein.

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