I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for the payment. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its content.

{todaysDate}

{patientsName}

{todaysDate}

{patientsName}

{todaysDate}

By signing this medical history questionnaire, I attest that the questions have been answered to the best of my ability. 

{patientsName}

{todaysDate}

ASSIGNMENT BENEFITS: 

I hereby assign all medical and surgical benefits, including major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other health/medical plan, to issue payment check(s) directly to HOPE HEALTH & WELLNESS, INC For Medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance or the agreed amount for services rendered.

The medical provider agrees to accept the irrevocable assignment of benefits for services rendered to the patient. This assignment applies to both past and future medical expenses. A photocopy of this assignment is to be considered as valid as an original. The undersigned patient agrees to pay any applicable deductible, co-payments, or for any and all other services not covered by the insurance policy. 

DIRECTION TO PAY: 

The undersigned patient further directs the insurer to pay HOPE HEALTH & WELLNESS, INC directly for the services rendered. Send payments directly to:

Hope Health & Wellness, INC

2845 North Military Trail West Palm Beach, FL 33409

Patient name: {patientsName}| Date: {todaysDate} | Date of Birth: {dateOf47}

Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. In an effort to keep cost down, while maintaining the highest level of professional care we have established the following policy.

ALL PATIENTS MUST COMPLETE OUR INFORMATION AND INSURANCE FORMS BEFORE SEEING THE DOCTOR. ALL PATIENTS ARE REQUIRED TO READ AND SIGN THE FOLLOWING FINANCIAL POLICY BEFORE TREATMENT BEGINS.

Financial Policy

PATIENTS WITHOUT INSURANCE

1. You will be required to make payment in full at the time services are rendered. We accept CASH, CHECKS, or CREDIT CARDS.

PATIENTS WITH INSURANCE

1. You will be required to make either payment in full at the time services are rendered or the amount of deductible and/or co-payment as confirmed by your insurance. We accept CASH, CHECKS, or CREDIT CARDS.

2. As a service to our patients, we will submit claims to your insurance companies and/or Medicare as a courtesy. However, this will in no way relieve you from your responsibility for paying for the services received.

3. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Therefore, it is your responsibility to be sure all required authorizations, referrals, or other conditions needed for payment have been met before treatment begins. If you have any doubts or questions, please contact our Insurance Department prior to your office visit.

4. Any claims we file on your behalf that remains unpaid after 60 days, from the date of service, you will be expected to pay in full. Please be aware that some, and perhaps all, of the services provided may be non-covered services and/or not considered reasonable and necessary under the Medicare Program and/ or other medical insurances. Also, due to differences in various insurance plans, the deductible and/or co-payments you pay at the time of service are only rendered as an estimate, therefore any portion of the total charge for services that are not paid by your insurance or Medicare will become your responsibility to pay.

5. Our practice is committed to providing the best treatment for our patients and our charges are usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

6. New patients being seen on an EMERGENCY basis will be expected to pay in full at the time of service. If insurance coverage can be confirmed by our Insurance Department during this visit, then only the confirmed deductible and/or co-payments will be required to be paid at this time of service.

7. If necessary, as in hardship cases, payment plans may be available and must be worked out before any treatment is received.

I have read and understand the above Financial Policy and agree to comply with the terms set forth. In the event of default, I hereby agree to be personally responsible for said debt including all cost of collection and attorney’s fees.

Patient Name: {patientsName} | Date: {todaysDate}

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy.

Implementation of HIPAA requirements officially began on April 14, 2003.  There are rules and restrictions on who may see or be notified of Protected Health Information (PHI).  These restrictions do not include the normal interchange of information necessary to provide you with office services.

HIPAA provides certain rights and protections to you as the patient.  We balance these needs with our goal of providing you with quality professional service and care.

Additional information is available from the US Department of Health and Human Services www.hhs.gov.

We have adopted the following policies:

1.  Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately.  This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care.  Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record.  The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front desk, examination room, etc.  Those records will not be available to persons other than office staff.  You agreed to the normal procedures utilized within the office for the handling of charts, patient records, PHI, and other documents or information.

2.  It is the policy of this office to remind patients of their appointments.  We may do this by telephone, email, or by any means convenient for the practice and or as requested by you.  We may send you other communications informing you of changes in office policy and new technology that you might find valuable or informative.

3.  The practice utilizes several vendors in the conduct of business.  These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

4.  You understand and agree to inspections of the office and review documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

5.  You agree to bring any concerns or components regarding privacy in the attention of the office manager or the doctor.

6.  Your confidential information will not be used for the purpose of marketing or advertising project products, goods, or services.

7.  We agreed to provide patients with access to their records in accordance with the state and federal laws.

8.  We may change, add, delete, or modify any of these provisions to better serve the needs of the practice and the patient.

9.  You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI.  However, we are not obligated to alter internal policies to conform to your request.

I have read and understood this document.

Patient Name: {patientsName} | Date: {todaysDate}