Start Here: Your Three-Step Journey to Fair Billing

We’ve streamlined our onboarding into three clear phases to protect your financial interests. To begin, follow the process below: Step 1 establishes our partnership through the Master Service Agreement, Step 2 secures your HIPAA privacy authorization, and Step 3 provides a dedicated channel for your medical bill uploads. Complete these steps to focus on healing while we handle the complexity.

STEP 1

Master Service Agreement

Your journey to billing advocacy begins here. Please review and sign the Master Service Agreement to allow us to begin auditing your healthcare costs and navigating insurance complexities on your behalf.

Master Service Agreement

Company: Faircare Advocates LLC

Client name*

Effective date*

Month

Day

Year

Section 1: Performance-Based Service Tiers

Please select one service tier:

Service tier selection*

Tier 1: Essential Bill Advocacy - Upfront: $49.00, Success Fee: 30% of total savings achieved, Coverage: Up to 2 medical bills

Tier 2: Complete Family Care - Upfront: $89.00, Success Fee: 25% of total savings achieved, Coverage: Bills from up to 3 different medical visits/procedures for one family member

Tier 3: Healthcare Billing Protection Plan (Monthly Membership) - Subscription: $49.00/month, Success Fee: 20% of total savings achieved, Value Guarantee: If savings don't exceed your annual fees ($588), FairCare refunds the difference (Year 1)

Section 2: Payment Terms

Savings Definition: "Savings" is defined as any reduction in the total patient responsibility amount through error correction, negotiation, or appeal.

Success Fee Billing: Success fees are invoiced immediately upon written verification of savings from the provider or insurance company.

Terms and Conditions

Service Limitations: Faircare Advocates provides advocacy services only and does not guarantee specific outcomes or savings amounts. Results may vary based on individual circumstances, provider policies, and insurance coverage.

Liability Limitation: Faircare Advocates' liability is limited to the fees paid by the client. The company shall not be liable for any indirect, incidental, or consequential damages arising from services provided.

No Attorney-Client Relationship: Services provided do not constitute legal advice, and no attorney-client relationship is established. Clients are advised to consult with qualified legal counsel for legal matters.

Termination: Either party may terminate this agreement with 30 days written notice. Upon termination, client remains responsible for any outstanding fees and success fees for savings achieved prior to termination.

Dispute Resolution: Any disputes arising from this agreement shall be resolved through binding arbitration in accordance with the rules of the American Arbitration Association.

Governing Law: This agreement shall be governed by the laws of the state where Faircare Advocates is incorporated, without regard to conflict of law principles.

I authorize Faircare Advocates to access my protected health information as described above for the purpose of medical bill advocacy services.

I acknowledge that I have read, understood, and agree to be bound by all terms and conditions of this Master Service Agreement, including the limitations of liability and dispute resolution provisions.

Client signature*

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Date signed*

Month

Day

Year

Pricing Plans

Tier 1: Essential Bill Advocacy$49

Tier 2: Complete Family Care$89

Tier 3: Healthcare Billing Protection Plan$49

HIPAA Authorization for Disclosure

This authorization allows FairCare Billing Advocates to access your medical billing information for forensic auditing and bill reduction services.

Authorized Party

FairCare Billing Advocates / Oshi Bernstein

Address:41- 31 Geiger Place, Fair Lawn NJ 07410

Phone: (917) 542-1651

Patient first name*

Patient last name*

Patient date of birth*

Month

Day

Year

Patient address*

Patient phone number*

Patient email address*

Information to be Disclosed

I authorize the disclosure of the following protected health information:

Select information to be disclosed*

Itemized Billing Statements showing CPT/ICD-10 codes

Explanation of Benefits (EOB) and Claims History

Correspondence regarding denied claims or prior authorizations

All billing records related to my care

Insurance claim documentation

Purpose of Disclosure

To perform a forensic audit and negotiate bill reductions on behalf of the patient.

Service tier scope*

Individual - Single patient only

Family - Patient and immediate family members

Unlimited Household - All household members

Select the scope of providers to be included in this authorization

Authorization Details

Scope: This authorization includes all providers associated with the selected service tier above.

Duration: This authorization remains valid for 12 months from the date signed unless revoked earlier in writing.

Right to Revoke: I understand that I may revoke this authorization at any time by providing written notice to FairCare Billing Advocates, except to the extent that action has already been taken in reliance on this authorization.

Re-disclosure: I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

Treatment Contingency: I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

Copy Rights: I understand that I have the right to receive a copy of this authorization.

I acknowledge that I have read and understand this authorization. I understand that by signing this authorization, I am authorizing the use and/or disclosure of my protected health information as described above. I understand that FairCare Billing Advocates will use this information solely for the purpose of performing forensic audits and negotiating bill reductions on my behalf.

Patient signature*

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Please provide your electronic signature to authorize this disclosure

Date signed*

Month

Day

Year

For Healthcare Provider Use

Provider Name: _________________________________

Provider Address: _________________________________

Date Received: _________________________________

Authorized Representative Signature: _________________________________

STEP 2

HIPAA Authorization for Disclosure Form

STEP 3

Please Upload any Bills, EOB, Insurance policy/ Coverage Details

First name*

Last name*

Email*

File upload*

Securely upload your itemized medical bills and EOBs here for a confidential forensic audit by our certified specialists

Signature*

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