FINANCIAL AGREEMENT & CONSENT FOR BILLING AND OUT-OF-NETWORK CARE
CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION
I give permission for the Midwife named above (“Provider”) to share the information needed for billing and insurance purposes with Lyons Medical Billing LLC. I also allow the Provider and Lyons Medical Billing to send the necessary information to my insurance company to help process claims.
TERMS OF THE PROVIDER’S FINANCIAL AGREEMENT
I understand that I am responsible for any part of the charges that my insurance does not pay. Insurance payments are considered reimbursements and do not change the Provider’s fee schedule or the amount I owe.
PRIVACY NOTICE
Lyons Medical Billing LLC follows all HIPAA rules and has a Business Associate Agreement with the Provider. My information will only be shared with the Provider and my insurance company as needed for billing. I acknowledge that I have received a copy of the Provider’s Privacy Policy.
LIMITS OF LYONS MEDICAL BILLING’S RESPONSIBILITIES (New Section)
Lyons Medical Billing LLC is committed to submitting claims accurately and according to billing guidelines. I understand and agree to the following:
1. Claim Corrections
If a claim is denied due to a billing mistake, Lyons Medical Billing will correct and resubmit the claim.
2. No Responsibility for Insurance Appeals
Lyons Medical Billing does not handle appeals for denied, reduced, or incorrectly processed claims.
All appeals are the responsibility of me, the patient, and must be handled directly with my insurance company.
3. No Guarantee of Insurance Coverage
Lyons Medical Billing is not responsible for:
insurance coverage being different than what was expected
changes in coverage
misquoted benefits
decisions made by the insurance company
Lyons Medical Billing does not guarantee:
what my insurance will cover
how claims will be processed
what benefits my insurance plan includes
the amount of reimbursement I may receive
Insurance coverage is determined solely by the insurance company.
4. Accuracy of Coding and Claim Submission
Lyons Medical Billing is responsible for:
accurately coding medical records based on documentation provided by the Provider
submitting claims according to national billing guidelines
submitting claims according to my chosen service level or care model (e.g., global maternity, itemized care, bundled services)
However, proper coding does not guarantee insurance payment, and I remain responsible for the Provider’s full fee.
OUT-OF-NETWORK STATUS, INSURANCE COVERAGE & BALANCE BILLING AGREEMENT
All Providers in this practice are Out-of-Network with all insurance companies. Lyons Medical Billing may help submit claims or request a “Gap Exception” when appropriate. However:
These steps do not change the Provider’s Out-of-Network status.
These steps do not limit the Provider’s right to collect their full fee.
By signing this agreement, I understand and agree to the following:
1. My financial responsibility
No matter how much my insurance pays—or if it pays nothing—I am responsible for the Provider’s full Midwifery Fee as listed in the Providers Financial Agreement. If I have not signed the Providers Financial Agreement, this agreement serves as my agreement to their Financial terms laid out in the Providers Financial Agreement.
2. Balance Billing
Because my Provider is Out-of-Network, I may receive a bill for the difference between the Provider’s fee and what insurance reimburses.
I understand this and agree to pay the remaining balance according to the Provider’s Financial Agreement.
3. Insurance payment is not guaranteed
Insurance companies may deny claims, reduce payments, or apply benefits differently than expected.
Any issues with insurance payments must be handled between me and my insurance company.
4. Gap Exceptions
If my insurance approves a Gap Exception, it does not:
make my Provider in-network
change the Provider’s fees
guarantee any payment from insurance
I remain responsible for paying the Provider’s full fee according to the Providers Financial Agreement.
5. Payment timeline
My payment responsibility does not depend on how long insurance takes to process claims.
Transfer of Care Clause
If I transfer to an in-network facility or another provider—whether due to medical necessity, patient choice, or any other reason—this Financial Agreement and the Midwife’s financial agreement remains in full force and effect.
I understand that fees charged by the receiving facility or provider are separate and are not included in the Midwifery Fee.
UNDERSTANDING AND AGREEMENT
These policies have been explained to me in clear language. I understand them and agree to the financial responsibilities described in this document.
STATE-SPECIFIC ADDENDUMs
(CA, WI, MN, TX)
California (CA)
California consumer protection laws (such as surprise billing rules) generally apply to emergency or in-network facility care.
Since midwives bill independently and are Out-of-Network providers, I understand that:
These protections usually do not apply to midwifery services, which are not Emergency services..
I am still responsible for the full Out-of-Network fee listed in the Provider’s Financial Agreement.
Wisconsin (WI)
Wisconsin does not have special laws preventing Out-of-Network billing for midwifery or routine maternity care.
I am responsible for any balance not paid by insurance under the Provider’s Financial Agreement.
Minnesota (MN)
Minnesota requires clear disclosure when providers are Out-of-Network.
By signing this form, I acknowledge that my Provider is Out-of-Network and that I am responsible for the full fee regardless of insurance coverage.
Texas (TX)
Texas “Surprise Billing” protections mainly apply to emergency or hospital-based care.
Independent midwifery services are not covered by that law, and I may still be billed for the balance of the Provider’s fee according to the Financial Agreement.