Please check all that apply in the following:

The Release of Information will remain in effect until terminated by me in writing.

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We are required by law to maintain the privacy of, and provide individuals, with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.
Signature below is only acknowledgement that you have received this Notice of Our Privacy Practices.

Signature below is only acknowledgement that you have received this Notice of Our Privacy Practices.

As a patient, you have the Right to:

• Considerate, respectful care at all times, and under all circumstances with recognition of your personal dignity.
• Personal and informational privacy, within the law.
• Information concerning your diagnosis, treatment, and prognosis to degree known.
• Confidentiality of records and disclosures. Except when required by law, you have the right to approve or refuse the release of records.
• The opportunity to participate in decisions involving your health care, unless contraindicated by concerns for your health. Make decisions about medical care, including the right to accept or refuse medical or surgical treatment and the right to initiate advance directives such as a living will or a durable power of attorney. If you already have a living will or advance directive, please speak to the nurse.
• Information concerning the implementation of any advance care directive.
• Impartial access to treatment regardless of race, color, sex, national origin, religion, handicap or disability.
• Receive an itemized bill for all services.
• Known the identity and profession status of individuals providing services to you. Report any comments concerning the equality of services provided to you at the Vein Treatment and Access Care and receive fair follow-up on your comments.

As a patient, you are Responsible for:

• Providing, to the best of your knowledge, accurate and complete information about your present health status and post medical history and reporting any unexpected changes to appropriate practitioner.
• Following the treatment plan recommended by the primary practitioner involved in your case.
• Providing an adult to transport you home after your procedure and to be responsible for you at home for the first 24 hours after your procedure.
• Indicating whether you clearly understand the contemplated course of action and what is expected of you.
• Your actions, if you refuse treatment, leave the facility against the advice of the practitioner, and/or do not follow the practitioner’s instructions relating to your care.
• Assuring that the financial obligations of your health care are fulfilled as expediently as possible.
• Providing information about and/or copies of any living will, power of attorney, or other directive that you desire us to know about.

If you have any questions regarding your rights and responsibilities, please discuss your concerns with us. I have received a copy of the above information.

I agree to be responsible to Vein Treatment and Access Car for all bills and charges, regardless of any insurance coverage that I may have. These charges are separate from any bills that I may receive from my doctor and/or anesthesiologist. I also agree to be responsible for all collection costs, including without limitation reasonable attorneys’ fees should my account become delinquent and is referred to an attorney or collection agency. I understand that an account shall be considered delinquent if:
a. It is not paid in full within 60 days from the date of service
b. It is not paid in full within 30 days from the date of initial billing or
c. Regardless of the amount of time that has elapsed since the initial billing; If I receive payment from an insurance carrier and do not tender it to Vein Treatment and Access Care within 5 days thereafter.
2. Vein Treatment and Access Care may release all or part of my records to any person or corporation which is or may be responsible for the payment of all or part of VTAC charges.
3. I authorize payment of medical benefits to Vein Treatment and Access Care for services rendered.
4. I certify that I have read and fully understand the above statements. I acknowledge that no guarantees have been made to me as the results of treatments or examinations performed in Vein Treatment and Access Care.