1. Consent to Medical Care and Treatment

I am being treated at Community Family Medical Clinic of Bunkie, and I consent to all medical and surgical care, examinations and tests determined by my physician that are necessary for me. Though I expect the care given will meet customary standards, I understand there are no guarantees concerning the results of my care. I also understand that if I do not follow my physician’s recommendation’s as they may relate to my health that the physician and this office will not be responsible for any injuries or damages that are the result of my non-compliance. I understand that if an employee or any individual associated with physician office is exposed to my blood or body fluids, I will be tested for the hepatitis virus and the (HIV I also understand that I will receive education related to this testing and that I will not be charged for testing and education related to the exposure.

2. Consent to Photograph, Videotape or Record

I authorize Physician Office to photograph, videotape or record me and agree that the negatives, slides, prints or tapes may be used for medical reasons. I hereby release physician’s office, its employees, physicians and other authorized persons, from any responsibility or liability which might arise from the taking and authorized use of negatives, slides, prints or tapes.

3. Consent to Use Of Information

Electronic Health Records. I understand that the physician’s office may collaborate with other health care providers to coordinate, manage and provide health care to me and I consent to the physician’s office sharing my health information and records electronically for the purposes of treatment, payment or operations, including improving the overall quality of health care services provided to me. I consent to the inclusion in the electronic health records of sensitive diagnose and related information such as HIV/AIDS status, sexually transmiVed diseases, genetic information, and mental health and substance abuse, etc. The (EHR) will be accessible by trinity health credentialed physicians/practitioners as well as other individuals approved to access the EHR for purpose related to treatment, payment, health care operations and or other purposes permitted by federal and state laws, including the Health Insurance Portability and (HIPPA The physician’s office has implemented administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of my medical information as required by HIPPA.

Use and Disclosure of Information. In addition to the above consent to use and share my health information with the Trinity Health EHR system,

I agree that the physician’s office may use and disclose my health information for a range of purpose including: treatment, eligibility verification, and or payment to private and public payers or their agents including insurance companies, managed care organizations, my employer (if I am injured at work), state and federal government programs, Workers’ Compensation programs, obtaining pre-admission or continued length of stay certifications, quality of care assessment and improvement activates, evaluating the performance of qualifications of physicians and health care workers, conducting medical and nursing training and education programs, conducting or arranging for medical review, audit services, ensuring compliance with legal, regulatory and accreditation requirements and public health and health oversight services.

Request for Information from Others. I consent to the physician office’s request of my health information from other providers of care to me, receipt of and release of my health information, whether wriVen, verbal, or electronic, for the uses described above as well as the physicians office’s participation in any health information exchange described in the (NPP Please refer to the NPP for additional, detailed information regarding the uses and disclosures of protected health information.

4. Acknowledge of Receipt of Notice of Privacy Practices

I acknowledge that I have received or been offered a copy of the physicians office’s notice of privacy practices which provides information on how the physician’s office may use or disclose PHI for purposes of treatment, payment, or health care operations.

5. Assignement of Benefits

I hereby assign to and authorize payment of all insurance and health care benefits available to me directly to the physician’s office for services provided to me. I understand that benefits may be payable to me directly if I do not provide this authorization.

6. Financial Responsibility

I understand and agree that I am financially responsible for payment of all charges incurred which are not paid by insurance or health care benefits, including any and all products provided or services rendered to me which are not eligible for payment (non-covered) under health care plans, Medicare, Medicaid or other insurance or payers. Non-covered services also may include those services my physicians determines to medically necessary, but are later determined unnecessary by the payer.

7. Personal Valuables

I understand that the physician’s office does not accept responsibility for any lost, stolen, or damaged personal items while I am at the physician’s office.

I understand that per my request, this authorization will permit the above-named parties to use or disclose the identified health information for purposes beyond treatment, payment, or healthcare operations as provided by health insurance portability and accountability act of 1996 (HIPPA I understand that I may revoke this authorization at any time. The revocation will be effective on the date It has been received and processed by the above-named recipient. I understand that the revocation does not apply to actions taken in reliance upon this authorization prior to the effective date of revoca$on. I also understand that I do not have to sign this authorization in order to receive treatment, payment or to enroll or be eligible for benefits. I understand that the information used or disclosed pursuant to this authorization may be subject to disclosure by the named recipient, and may no longer be protected by the HIPPA privacy rules after the authorized disclosure.

All professional services rendered are charged to the patient and are due at the time of services, unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments. The price quoted is the cash or check price if you choose to pay credit or debit, a non cash adjustment of 4% will be added to the transaction.

I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carriers, including Medicare, private insurance and other health. Medical plans, to issue payment checks directly to Community Family Medical Clinic medical services rendered to myself and or my dependents regardless to my insurances benefits if any. I understand that I am responsible for any amount not covered by insurance.

I hereby authorize Community Family Medical Clinic: (1) release my information necessary to insurance carriers regarding my illness and treatments. (2) Process insurance claims generated in the course of examination or treatment. (3) Allow a photocopy of my signature to be used to process insurance claims for the period of lifetime. This order will remain in effect until revoked by me in writing. I have requested medical services from Community Family Medical Clinic on behalf of myself and or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized. I future understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full. A photocopy of this assignment is to be considered as valid as the original.