CONSENT TO TREATMENT, AUTHORIZATION FOR MEDICAL RECORDS RELEASE/REFERRAL AND ASSIGNMENT OF BENEFITS AND PATIENT RIGHTS AND RESPONSIBILITIES: I.
I hereby consent and authorize Community Health Center of Central Wyoming (CHCCW) to furnish me or the above registered patient with necessary medical or dental care. This care may include ancillary care including but not limited to laboratory testing, radiologic examinations and other diagnostic procedures as deemed necessary by the professional staff at CHCCW. I understand that the services recommended to, or provided to me are in my, or the registered patient’s best interest. I understand that I have and reserve the right to revoke this consent at any time and for any reason during my treatment at CHCCW. I consent to be contacted by mail, email, and telephone regarding matters related to my treatment or patient account by CHCCW and entities formally associated with CHCCW.
I authorize CHCCW to release protected health information to persons or entities directly associated with and engaged in carrying out a treatment plan for the patient. CHCCW may use and release any part of my medical records necessary to the process of billing third party payers for services rendered on my behalf. I clearly understand that all my information will be kept confidential. I consent for CHCCW to use technology, including automated technology such as auto-dialing or pre-recorded messages, to contact me at the address, e-mail address, or telephone number, including any cell phone/wireless number that I have provided; I understand that this information will be used to review, investigate, make payment of a claim, to review records for quality improvement initiatives, audit compliance, utilization management, or complaint resolution. I authorize payment directly to Community Health Centers of Central Wyoming for all medical or dental benefits otherwise payable to me under terms of my insurance. I understand that I am financially responsible for all co-payments, co-insurance, deductibles, and non-covered services. Overpayments on my account at Community Health Centers of Central Wyoming account may be applied to my patient balance.