I certify that I and/or my dependent(s) have insurance coverage and assign directly to Well Life Medical, PC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Well Life Medical, PC may use my health care information and may disclose such information to my and/or my dependent(s) insurance company(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services.

This consent will end when my current treatment plan is completed or one year from the day this form is submitted.

HIPAA Privacy Notice

Our Legal Duty:

We are required by law to protect the privacy of your medical information, provide you a notice about our privacy practices and follow these practices described in this notice. If you have questions or complaints, you may contact the Practice Manager at the office of Well Life.

2 First Avenue Suite 215
Peabody, MA 01960
(978) 740-2300.

Our notice of privacy practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this acknowledgment. As provided in our notice, the terms of our notice may change. If we change our policy, you may obtain a revised copy by contacting Dr. Francis M. Harte, MD.

Complaints:

If you think that your privacy rights have been violated, or if you disagree with a decision we made about the use or access to your records, you may contact the Practice Manager. You also may send a written complaint to the:

U.S. Department of Health and Human Services
200 Independent Avenue S.W.
Washington D.C. 20201.

The telephone number is (877) 696-6775

Nothing, except the above mentioned, will be released without your written permission. This will include family, or request for records by outside sources.

Financial Policies

PAYMENT is expected at the time of your visit. We will accept cash, check, or credit card. Payment will include any unmet deductible, co-insurance, co-payment amount, or non-covered charges from your insurance company. If you do not carry insurance, payment in full is expected at the time of your visit.

INSURANCE:  We are participating providers with several insurance plans.  We will file all of these insurance claims. In order to do this, we require all information to be completed on the Patient Registration Form.  We must have this information prior to your appointment.  We will request an update to your information at each visit.  Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full.  If your insurance company does not pay the practice within a reasonable period of time, you will be billed.  If we later receive payment for your insurer, we will refund any overpayment to you.

If our doctors are not listed in your plan’s network, you may be responsible for partial or full payment.    Due to the many different insurance products out there, our staff cannot guarantee your eligibility and coverage.  Please contact your insurance company at the customer service phone number printed on your insurance card if you have questions pertaining to coverage.

Not all insurance plans cover all services.  In the event your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge.  Payment is due upon receipt of a statement from our office.  All procedures billed in this office are considered covered unless limited by your specific insurance policy.  Please note that this does not include alternative services (i.e Acupuncture, Acutonics, Reiki, Aromatherapy or classes and workshops).

INVOICES:  If you receive an invoice from our office for a balance due, it is because that is the balance your insurance policy requires you to pay.  Please contact your insurance company first if you think there is a problem.  The balance on your invoice should be equal to the “Patient Responsibility” portion on your Explanation of Benefits that you receive from your insurance company plus any “non-covered services” (less any copay that was collected at the time of service).  If you believe there is a discrepancy, please call us at (978) 740-2300, ext. 201 and speak to our billing staff to advise.  You will continue to receive invoices and be subject to collections if you do not advise us of discrepancies.

COLLECTIONS:  Invoices not paid within 30 days begins our collections process.  Invoices not paid within 90 days are subject to patient dismissal and submission to Carter Business Services, Inc. and notification to your insurance plan.  The following services are considered “non-covered” services:

• Returned check:  If your check is returned to us for any reason, you will be assessed $25.00 fee.  You will be asked to bring cash, certified funds or a money order to cover the amount of the check plus the $25 service charge to pay the balance prior to receiving services from our staff or the physician.  All bad checks written to this office are subject to collections.  No further checks will be accepted.
• Missed appointment:  If you fail to notify us at least 24 hours in advance you may be charged $25.00 for an office visit; and $50.00 for a scheduled physical and all alternative services.
• Late Fees:  Invoices not paid within 30 days will result in a $10.00 per month late fee.
• Collection Fee:   20% collection fee in addition to collection account must be paid.

RESPONSIBILITY FOR PAYMENT:  I acknowledge that acceptance of my insurance information is not a guarantee of payment by my health plan until the claim has been accepted and processed.  I further understand that if my claim is not accepted for payment I am personally responsible for payment of medical services rendered to me.

RESPONSIBILITY FOR COPAYMENT:  I agree to pay all applicable health plan copayments at the time of service.

PAYMENT PAST DUE:  I understand that all health plan deductibles and charges for non-covered benefits are due and payable upon presentation of a billing statement from Well Life Medical.  I also understand that all invoices remaining unpaid after 30 days will incur a $10 per month late fee until the balance is satisfied.

DELINQUENT ACCOUNT:  I understand that Well Life Medical assigns delinquent accounts to Carter Business Services, Inc.  In the event my account is sent to collections, I am aware that I will be asked to pay a 20% collections fee in addition to the balance due until the balance is paid.  All payments made to Well Life Medical must be made in cash or credit card only.

Massachusetts Health Information Highway

The Mass HIway is a secure, statewide network that allows my healthcare providers to safely and quickly share important information about me when and where it is needed for my care (such as my allergies, medications, and health history) with the goal of improving communication among hospitals and doctors and providing better quality care to patients.

Partners HealthCare System, Inc. (“Partners HealthCare”) and/or its affiliated entities and healthcare providers have provided me with information about the Mass HIway. I understand that Partners HealthCare has developed an integrated electronic medical record that is used by Partners HealthCare, its affiliated entities and healthcare providers and other non-partners healthcare providers such as Dana-Farber Cancer Institute, Massachusetts Eye and Ear Infirmary and certain community physicians and physician groups. I acknowledge that by signing this form below I consent to and agree that Partners HealthCare and its affiliated entities and healthcare providers and all other users of the Partners integrated electronic medical record (including but not limited to Dana-Farber Cancer Institute and Massachusetts Eye and Ear Infirmary) may request, access, send and receive my health information using the Mass HIway. I understand that the information accessed or shared using the Mass HIway may also include information created by other healthcare providers and organizations and used by Partners HealthCare and/or its affiliated entities and healthcare providers to provide care to me.

I understand that I can withdraw my consent to share my health information using the Mass HIway at any time by contacting any of the Partners HealthCare hospital privacy offi ces and completing the Partners HealthCare Mass HIway OPT-OUT form.