Please check all that apply in the following:
The Release of Information will remain in effect until terminated by me in writing.
The best time to reach me is (day) day between (time) time
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:
As a patient, you are Responsible for:
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 serviceb. It is not paid in full within 30 days from the date of initial billing orc. 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.