Assignment of Benefits and Release of Information

I acknowledge and accept responsibility for the payment of healthcare services provided to me, and I authorize and consent to the facilitation of payment by Zaya Care on behalf of the licensed providers affiliated with the medical practices managed by Zaya Care.

Zaya Care refers collectively to the affiliated professional entities Bienetre Medical PC (New York) and Bonheur Medical PC (New Jersey), which operate in affiliation with their management services organization, Zaya Care, Inc. Zaya Care, Inc. serves as a HIPAA Business Associate to these affiliated practices and supports their operational needs, including administrative, billing, and compliance functions. Throughout this document, the terms “Zaya Care,” “we,” “us,” and “our” refer to this collective organization. The affiliated entities form an Organized Health Care Arrangement (OHCA) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Assignment of Benefits

I hereby assign all applicable health insurance benefits to Zaya Care for services rendered by its affiliated providers. I authorize Zaya Care to process claims and receive payments directly from my insurance company or third-party payor on behalf of the affiliated entities where care is delivered. I understand and agree that in the event my insurance plan makes payment directly to me, I am responsible for promptly remitting such payments to Zaya Care, unless I have already satisfied the charges in full.

Release of Information for Payment Purposes

I authorize Zaya Care to disclose any medical, billing, or treatment information necessary to my insurance carrier(s), including Medicare, Medicaid, supplemental insurance providers, and private insurers, for the purpose of obtaining payment for services rendered. This includes electronic and paper submission of claims, and any communication with insurance representatives necessary to resolve or appeal payment issues. I also authorize my provider and Zaya Care to act as my agent in these matters.

Insurance and Managed Care Plans

If Zaya Care is an in-network provider with my insurance plan, I agree to pay all required deductibles, co-payments, coinsurance, and other out-of-pocket obligations. If my insurance benefits are exhausted or terminated, Zaya Care will notify me, and I understand that I will be financially responsible for services rendered thereafter. If a claim is denied despite proper billing procedures, I understand I may be responsible for payment in full.

Medicare Authorization

If I am a Medicare beneficiary, my signature on this form authorizes payment of benefits to Zaya Care and its affiliated providers. I also authorize the release of any medical or billing information required to process Medicare claims. In Medicare-assigned cases, I agree to be responsible for any applicable deductibles, coinsurance, or non-covered services based on Medicare’s determination of charges.

HIPAA Privacy and Security Protections

Zaya Care is committed to protecting the confidentiality, privacy, and security of your Protected Health Information (PHI) in accordance with HIPAA and all applicable federal and state laws. As part of the OHCA, the affiliated entities may share PHI among themselves for purposes of treatment, payment, and healthcare operations, as permitted by HIPAA regulations (45 CFR §§ 164.502 and 164.506).

Zaya Care maintains strict physical, technical, and administrative safeguards to prevent unauthorized use or disclosure of PHI. Your information will not be used for any purpose outside of treatment, billing, and operations unless you provide explicit written consent, except as otherwise required or permitted by law.

You have the right to:

• Request restrictions on the use or disclosure of your PHI
  
  

• Access and obtain copies of your health records
  
  

• Request amendments to your PHI if you believe it is inaccurate or incomplete
  
  

• Receive an accounting of certain disclosures of your PHI
  
  

• File a complaint if you believe your rights under HIPAA have been violated
  
  

For any questions or concerns regarding your privacy rights, you may contact Zaya Care’s Privacy Officer through compliance@zayacare.com.

Acknowledgment and Authorization

By signing below, I acknowledge that I have read and understand the terms of this Assignment of Benefits and Release of Information form. I hereby authorize Zaya Care and its affiliated providers to bill my insurance carrier directly and to receive payment of benefits for services rendered. I understand that I am financially responsible for any charges not covered by my insurance plan.

Furthermore, I authorize Zaya Care and its affiliated providers to release my Protected Health Information (PHI) as necessary to my insurance carrier(s), healthcare clearinghouses, and any other entities required for the purpose of treatment, payment, and healthcare operations, in accordance with applicable federal and state privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA).

Patient Name: _________________________________________

Date of Birth: ________________________

Signature of Patient or Authorized Representative: ___________________________

Date: ________________________

If signed by Authorized Representative, please print name and relationship to patient:
 Name: _________________________________________
 Relationship: ____________________________________

Provider Name: __________________________________________

Provider Signature: ________________________________________

Date: ________________________