Insurance Billing for Everything Home Birth and Birth Center Related
EarthSide Billing, Inc.
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Please enter the Pregnant Mother's Information
First Name
Last Name
Date of Birth
Estimated Due Date
Email
Phone
Street Address
City
State
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District of Columbia
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West Virginia
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Zip
Planned Birth Location
Home Birth
Birth Center
Other
Name of Midwife or Group
Read HIPAA Disclosure and Disclaimer
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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 does not guarantee claim payment or reimbursement.
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.
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Insurance Company
Insurance ID#
Insurance Group#
Insurance Card Front
Insurance Card Back
Supplementary Insurance
2nd Insurance Company
2nd Insurance ID#
2nd Insurance Group#
2nd Insurance Card Front
2nd Insurance Card Back
Insurance Subscriber's Name
Same as Pregnant Mother
Other
Subscriber's First Name
Subscriber's Last Name
Subscriber's Relation to Mother
Spouse
Domestic Partner
Parent
Subscriber's Date of Birth
Subscriber's Address
Same as Pregnant Mother
Other
Subscriber's Street
Subscriber's City
Subscriber's State
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Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Subscriber's Zip
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Card Number
Expiration Date
CVC
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