Assignment of Benefits and HIPAA

Assignment of Benefits
I authorize Bayside Pediatric Therapy to release any of my medical information along with any of my child’s medical information, to my insurance company(s), as needed to process my insurance claim for rendered services. I authorize my insurance company to make payments directly to Bayside Pediatric Therapy covered medical services.

Insurance/Payment Information

I understand that I am responsible for any amount not covered by insurance: this includes any course of treatment that is not a covered benefit.

I understand that if my account is turned over to a collection agency due to non-payment, my debt may increase up to an additional 50%.

I understand that it is my responsibility to notify Bayside Speech Therapy, Inc. of any physician and/or insurance change.

I understand there will be a $25 “no-show” fee (for non-medicaid patients)

My signature below indicates that I am the legal guardian of this patient and that I understand and accept this policy.

 

HIPAA Privacy Authorization Form

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

Bayside Speech Therapy, Inc. is required by law to protect the privacy of health information that might reveal your identity. We are required to provide you this notice about our health information privacy practices and follow the information practices that are described ion this form. You will be asked to sign an “acknowledgement” statement, indicating that you have been provided with this notice.

All employees, trainees, and students are required to follow these policies.

This notice refers to services in the patient’s home or natural environment.
Exceptions: If you receive treatment in a facility or location not owned or operated by Bayside Speech Therapy, Inc., other policies may apply.

Federal laws define “Protected Health Information” (or PHI) as any individually identifiable health information. It refers to protected health information that is created or received by or on behalf of Bayside Speech Therapy, Inc. contained in the patient’s medical record or files, whether oral or recorded in any form or medium.

Bayside Speech Therapy, Inc. uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and, evaluating the quality of care that we provide. Bayside Speech Therapy, Inc. may use your personal health information to communicate with you about treatment, obtain payment for service or conduct our business operations. (Example: to provide appointment reminders.) Our staff may communicate information with you via telephone, fax, voice message, electronic/text message, email or other. However, we will obtain your permission to do so, or we are responding to an inquiry that you initiated via that method.

Bayside Speech Therapy, Inc. may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, and for emergencies. We also provide information when required by law. Bayside Speech Therapy Inc. may use or disclose your health information if we have removed any information that might identify you.

In any other situation, Bayside Speech Therapy, Inc.’s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time

You may request that we transfer your records to another person or organization by completing a written authorization form.

You have the right to access, inspect or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request an accounting of disclosures, with the exception of routine disclosures for treatment, payment and business operations.

If you are concerned that Bayside Speech Therapy, Inc. may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below:

Victoria Coe, info@baysidepediatrictherapy.com

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Bayside Speech Therapy, Inc. is required by law to keep your health information safe. This information may include:

Notes from your doctor, teacher, or other health care provider
Your medical history
Your test results
Treatment notes
Insurance information

We are required by law to give you a copy of our privacy notice. This notice tells you how your health information may be used and shared. It also tells you how you can look at and comment on your information.

By signing this page, you are saying that you have been given a copy of our privacy notice.