CONSENT: The information on this form is true to the best of my knowledge. I voluntarily consent to out-patient care at Mid-Delta Health Systems which may include diagnostic procedures, examinations, and/or treatment by MDHS’s providers and/or other staff of the clinic.
RELEASE OF INFORMATION: I authorize Mid-Delta Health Systems to release medical information to third-party insurance carriers for the purpose of filing claims, and to release or obtain medical information to/from providers of medical care and the Health Department for the purpose of continuity of care. I authorize payment of medical benefits by my insurance to Mid-Delta Health Systems. I consent for those listed on this form to receive any and all information regarding my healthcare, personal observations and concerns, treatment plans, and prognosis.
PRESCRIPTION HISTORY CONSENT: This facility participates in the Prescription Drug Monitoring Program. Clinicians in this office will not prescribe narcotics, benzodiazepines, or controlled medications for chronic use. I authorize Mid-Delta Health Systems to obtain and review my prescription history from pharmacies, other providers, and other third-party entities such as insurance companies.
TRAINING FACILITY: I understand that occasionally health care students may be working with my provider. I give consent to have a health care student observe or participate in my care while under the supervision of my provider. I understand that these health care students are under the same confidentiality policies as my provider. I acknowledge that I have the option of declining consent.
PATIENT BILL OF RIGHTS/PRIVACY NOTICE: If I want one, I have been given a copy of Mid-Delta Health Systems Patient’s Rights and Privacy Notice.
EFFECTIVE PERIOD: I understand this consent/authorization will be valid and remain in effect as long as I attend the clinic or until I revoke this authorization in writing.
Medicaid/ARKids: I understand that if I have Medicaid, this facility must be designated as my Primary Care Physician. If Mid-Delta Health Systems is not my PCP, I acknowledge that I must obtain a referral for services from my PCP or the full amount of services will be due at the time of visit. I understand I am responsible for ANY services not covered by Medicaid or ARKids.
Medicare: I understand that I will be responsible for any service or lab not covered by my Medicare or Medicare replacement plan.
Sliding Fee Scale/Self-Pay: I understand that Mid-Delta Health Systems offers reduced fees on a sliding fee scale based on household income. If I wish to apply for the sliding fee scale, I will fill out the provided form and return my proof of income within 48 hours of visit. If I qualify for reduced fees, I understand that I will be asked to pay an initial fee of $15 for medical or $30 for dental at check-in. Any remaining charges will be collected at check out. If I do not have insurance and do not qualify for the sliding fee scale, I will be asked to pay a set fee of $15 for medical or $30 for dental at check-in and additional charges at check-out.
IF YOU ARE UNABLE TO PAY ANY OF THE ABOVE FEES AT THE TIME OF YOUR VISIT YOU MAY BE RESCHEDULED.
It is necessary for us to ask personal questions in order to give you a discount on your medical/dental expenses. This information will be kept on file in our clinic in strict confidence. You must verify your income at least once every year. Proof of Household Income may include:
Your annual household income will be used to calculate the level of your discount.