Compliance & Privacy
HIPAA Authorization for Disclosure
Click here to fill out the HIPAA Authorization Form.
This HIPAA Authorization Form grants FairCare Billing Advocates LLC the legal permission to access, review, and discuss your protected health information (PHI) with your healthcare providers and insurance carriers. This authorization is essential for our advocates to conduct medical audits, verify coding accuracy, and negotiate billing reductions on your behalf.
1. Patient Information and Authorization
By executing our engagement documentation, I authorize my healthcare providers, hospitals, clinics, and insurance carriers to disclose my medical and billing records to Oshi Bernstein and the authorized team at FairCare Billing Advocates LLC.
2. Specific Records to be Released
- All itemized billing statements and hospital charges.
- Clinical documentation and physician progress notes justifying specific charges.
- Insurance Explanations of Benefits (EOB) and correspondence.
- Laboratory, radiology, and diagnostic test results.
- Pharmacy records and medication administration logs.
3. Purpose of the Disclosure
The information is to be used for the purpose of identifying billing errors, overcharges, CPT/ICD coding inaccuracies, and facilitating negotiations for the reduction of the patient's financial liabilities. Information may also be used to file formal insurance appeals and clinical grievances.
4. Rights, Expiration, and Revocation
This authorization is valid for a period of one (1) year from the date of signature unless otherwise specified. I understand that I have the right to revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my signing this authorization.
Note: FairCare Billing Advocates LLC adheres to all Federal Privacy Rules as outlined in the Health Insurance Portability and Accountability Act (HIPAA). Your records are handled within a secure, encrypted environment and are never shared with third parties for marketing purposes.
HIPAA Authorization Form
01. Patient Information
Patient Information
Please ensure all demographic details are completed below: Full Legal Name, Date of Birth (via date picker), Street Address, City, State, ZIP Code, Phone Number, and Email Address. This information is required to accurately match your clinical and billing records.
02. Recipient Information
Authorized Recipient (Locked)
FairCare Billing Advocates LLC / Oshrat Bernstein
Fair Lawn, NJ 07410
* This section is pre-authorized and locked for your security.
03. Records for Release
Scope of Authorization
Check the appropriate boxes in the interactive form below to release specific itemized billing statements, clinical documentation, insurance EOBs, lab results, or pharmacy records.
04. Purpose and Rights
Verification & Expiration
The information disclosed will be used to identify billing errors and negotiate reductions. This authorization remains valid for one (1) year from the date of signature unless otherwise revoked.
05. Signature Block
Electronic Submission
Complete all fields below including your digital signature, date, and relationship to the patient to finalize this authorization.
FairCare Billing Advocates LLC adheres to all Federal Privacy Rules as outlined in HIPAA. Your records are handled within a secure, encrypted environment and are never shared with third parties for marketing purposes.