Faried Banimahd MD, Inc

I the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to FARIED BANIMAHD, MD all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorize the use of this signature on all insurance submissions.

1. Payment is due at the time of service, unless otherwise notified by intake staff members. We accept cash, checks, and credit cards.

2. All copayments, deductibles and noncovered services must be paid in full at the time of the service, unless otherwise notified by intake staff members.

3. Our office will submit claims to your insurance company as a service to you. It is important that you know what your insurance plan covers. Services not covered by your insurance are your responsibility.

4. If your insurance company requires laboratory specimens be sent to a specific lab, it is your responsibility to know the participating lab. Please be aware of the plan requirements.

5. If your insurance is a managed care plan, please review your coverage. If you require services that require a referral, adequate planning is essential. Referrals must be authorized by your doctor and usually requires an office visit. Authorization from managed care plans for your referral may take one or more days. Please be aware that we are unable to accommodate call in requests for referrals. Failure to obtain necessary authorizations often lead to out of pocket expenses. We are happy to assist you in any way with your managed care plan, however our experience with these plans has demonstrated that planning and adequate lead time is essential. Your knowledge of your regulations and benefits will help avoid delays and/or denied claims.

6. In the case of estranged parents or divorced parents, the parent accompanying the child to the visit is responsible to pay for services rendered regardless of coverage arrangements. We will gladly furnish you with statements for reimbursement.

7. Your doctor is here to manage your medical care. The physicians are not experts on insurance and cannot be aware of all financial arrangements. Please discuss insurance problems and financial arrangements with the office staff.

8. If you are experiencing financial difficulties, please discuss this with the office staff. We will gladly work with you to make payment arrangements. Accounts over 30 days past due will be referred to collections department and upon their determination may be referred to legal department for collection. You will be responsible for additional costs of collections, including legal fees, if incurred.

I have read the above acknowledgements and agreements and fully understand the same.

1. Prescription refill requests must be called into the staff five days in advance and must be approved by physician. In addition, there is NO guarantee of approval upon the request. An appointment is usually necessary.

2. Messages left for refills will not be honored.

3. Early prescriptions request due to lost/stolen medication or scripts must be accompanied by a police report. No exceptions.

4. Emergency prescription requests less than 24-hour notice, if approved, will have a service fee of $25.

Thank you for your cooperation and understanding. I have read the above acknowledgements and agreements and fully understand the same. 

1. I understand that my health care provider wishes me to engage in a telemedicine consultation. I hereby authorize Zephyr Medical Group to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.

2. My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that

the videoconferencing connections are not adequate for the situation.

4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

5. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.

6. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference

7. I understand that billing will occur from both my practitioner and as a facility fee from the site from which I am presented. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.

8. I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

9. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me

• That I fully understand its contents including the risks and benefits of the procedure(s).

• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

For the Use and Disclosure of Health Information, Payment, or Healthcare Operations. 42 CFR Part 2 HIPAA (Must be completed and returned by patient prior to treatment)

I understand that Zephyr Medical Group originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and my plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment
• A means of communications among the many health professionals who contribute to my care
• A source of information for applying my diagnosis information to my bill
• A means by which a third-party payer can verify that services billed were provided
• A tool for routine healthcare operations such as assessing quality and reviewing the competence healthcare professionals

I understand that Zephyr Medical Group is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization as already action in reliance thereon, I also understand that refusing to sign this consent or revoking this consent, Zephyr Medical Group may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that Zephyr Medical Group reserves the right to change their notice and practices in accordance with Section 164.520 of the Code of Federal Regulations. I understand that as a part of this organization’s treatment, payment or healthcare operations, it may become necessary to disclose any protected health information to another entity, and I consent to such disclosure of these permitted uses.

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.

I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations