Authorization to Release Information

I authorize the release of medical information to my primary care or referring physician and as necessary to process insurance claims, including claims for disability benefits, insurance applications and prescriptions. I authorize transmission of medical information by fax.

Acknowledgement of Receipt of Notice of Privacy Practices

I have received a copy to review of the Notice of Privacy Practices of Stay Active Southen Indiana and Dr. G. Stan Schooler.

RX Refills

"I agree that Stay Active Southen Indiana/Dr. G. Stan Schooler may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payers for treatment purposes."

Acceptance of Financial Responsibility

I acknowledge full financial responsibility for services rendered by AA/Dr. Schooler, regardless of insurance coverage, Workman's Compensation coverage and whether or not there was an accident with another party at fault. The patient is responsibly for furnishing current insurance information and acknowledge patient/responsible party is aware of their own insurance coverage and plan. In addition to charges collected at the time of service, SA/Dr. Schooler may bill me for additional services provided (i.e., braces, boots, taping, etc.) and or balances on my account.

Outstanding Balances

I acknowledge if my account has an outstanding balance, I will not be able to make an appointment until the balance is paid in full. Any third party costs associated with collecting past due accounts (40% increase) will be added to patient's account.

Insurance Patients

AA/Dr. Schooler will file your insurance. I authorize my health insurance company to utilize the medical information as reasonably necessary for the proper administration of the health plan. I hereby assign AA/Dr. Schooler any payments of medical benefits for services rendered to myself or dependents.

Co-payments: AA/Dr. Schooler is required to collect your co-payment. If not paid, you will be billed and/or sent to collection with an additional 40% increase. I have read and understand that I am responsible for paying the annual deductible, co-payment, coinsurance and any charges for non-covered services as determined by my insurance.

Self Pay Payments

Patients will need to make a $125.00 deposit prior to seeing the provider and if there are any addition charges (ie., braces, boots, taping, etc.), you will be billed.