I give permission for J.C. Healthcare & Associates, LLC to give me medical treatment.

2.I understand that J.C. Healthcare & Associates will not submit a claim for insurance benefits to pay for the care I receive, unless it is done at the discretion of the provider.

• I understand that:
  • All services I receive must be paid by debit or credit card in full at time of service.
  • It is my responsibility that if I have insurance, I will contact my insurance company to discuss reimbursement of services paid for.
  • I must pay for the cost of these services if even if my insurance does not pay or I do not have insurance.

3. I understand:

• I have the right to discuss all medical treatments with my healthcare provider.
• I have the right to request to be seen or referred to another healthcare provider such as a physician or nurse practitioner.
• I have the right to refuse any procedure or treatment.

Parent/Guardian Signature (for minors under 18) Date

Responsible Party or Insurance Policy Holder (Skip if no health insurance)

Medical Insurance Company Information

Meaningful Use (required by law)

 

You will be required to provide a government issued photo ID at the time of service.

J.C. Healthcare & Associates reserves the right to charge a fee for any scheduled visits that are:

Cancellation Fee:

New Patient $30.00  

Established Patient: $20.00

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon execution of this consent.

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

 

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. This is readily available to view anytime on our website at www.jchealthcareassociates.com. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA

• Protected health information may be disclosed or used for treatment, payment or health care operations • The Practice has a Notice to Privacy Practices and that the patient has the opportunity to review this Notice

This Acknowledgement was signed by:

Practice Representative: Jessica Chung