Over the past 2 weeks, how often have you been bothered by any of the following problems? Rate your answers as follows:
Not At All = 0
Several Days = 1
More than Half the Days = 2
Nearly Every Day = 3
Column Totals -- blanks + + +
I am enrolled in the following insurance plan(s). Please put self-pay if applicable.
I acknowlege that I have voluntarily sought the services of Atkinson Family Practice and Katherine Atkinson, MD, PC, a participating provider. I accept full responsibility for paying for services provided by Atkinson Family Practice and Katherine Atkinson, MD, PC. I understand that my insurer will not pay the provider nor reimburse me for the cost of services rendered here, or for any subsequent or ancillary services which the provider may order on my behalf, if this insurance is not truly in effect or if the provider is not considered my primary care physician. I further acknowledge that it is my responsibility and not the provider's to know what services are covered by my insurer. I accept full responsibility for paying for services provided if they are not cocered by my insurance. If the above information changes at any point, it is my responsibility to notify Atkinson Family Practice.
I certify that I and/or my dependents assign our insurance benefits directly to Katherine J. Atkinson, MD, PC and its employees have the right to disclose my (or my dependents') health care information to my insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits and payments for related services.This consent will remain active unless I cancel it in writing.
Due to HIPAA regulations, we may only discuss health information with people that you have listed below (that includes parents and/or spouses).
Please note that this consent will be valid for one year from date signed. If your contact information changes before the end date, please complete a new form. This may be revoked at any time, in writing. The information is for your protection and we appreciate your cooperation in protecting you and your rights.