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THE FOLLOWING TERMS, CONDITIONS AND POLICIES ARE IMPORTANT AND WILL GOVERN YOUR RELATIONSHIP WITH AND LEGAL OBLIGATIONS TO MULTI-CARE SPECIALISTS, S.C.

("MULTICARE") AND ITS HEALTHCARE PROVIDERS, INCLUDING ASHLEY EAVENSON D.C.; JONATHON BROOKS D.C.; KEVIN BELL M.D.; AMANDA BASHAM FNP-BC .; COREY VOSS P.T.; and TATE MERTEN CAT. ("PROVIDERS"). YOU SHOULD READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.

Consent to Treatment

Multi-Care and Providers are hereby authorized to provide treatment and health care services to patient.

Payment

Payment, including co-payments and deductibles if applicable, is due on each date of service for the services rendered on that date, unless other arrangements have been made in writing. Unless otherwise agreed in writing, Multi-care is entitled to receive the standard rates set forth from time to time in its published fee schedule for the services provided to patient, plus all out of pocket expenses reasonably incurred for patient's care. Multi-care is entitled to receive the reasonable value of any services provided to patient that are not specifically listed in Multi-Care's published fee schedule.

24-hour notice of appointment cancellation is required. A cancellation fee of $50.00 is payable for any missed or cancelled appointment if timely notice of cancellation has not been given. Health insurance and other health care benefit plans do not typically pay fees for late cancellations or missed appointments. 

If payment is not made when due, Multi-Care will be entitled to recover all costs of collection incurred, including reasonable attorney fees.

Assignment of Benefits

If patient or patient's representative is entitled reimbursement or payment of amounts payable to Multicare Specialists or Providers by an insurance carrier, benefit plan or other third party payer ("Payment Sources"), Multicare Specialists is authorized to submit claims to Payment Sources on behalf of patient or patient's representative. However, except as otherwise required by law, Multicare Specialists may, in its sole discretion, elect (a) not to submit claims for all or any part of its services, (b) not to submit claims to one or more Payment Sources, and ( c) accept payment from any one or more of Payment Sources, without waiver or reduction of any right or claim to payment from patient or patient's representative or from any other source. Except to the extent otherwise allowed by law, patient (or, if applicable, patient's representative) shall remain primarily responsible for payment even if Multicare Specialists fails to submit claims to one or more potential Payment Sources or if Multicare Specialists is not paid in full by the Payment Sources to which claims are submitted.

To the fullest extent allowed by law, patient ( or, if applicable, patient's representative) hereby assigns to Multicare Specialists any and all rights to payment from any one or more of Payment Sources for healthcare services now or hereafter provided to patient by Multicare Specialists or Providers, including
(without limitation): (a) amounts payable under any private or public insurance or other benefit plan, including any group or individual accident, disability or health insurance policy or benefit plan or any automobile insurance policy; (b)compensation payable for such services under worker's compensation, occupational disease or other comparable laws; and (c) all proceeds of any claim or cause of action for personal injuries giving rise to such services.

Emergency

If patient has a medical emergency, patient ( or patient's representative, if applicable) should contact Multicare Specialists, but if unable to reach a Provider, should call 911 or go to the nearest emergency room.

Representative

If this document is signed by a representative, the representative represents and warrants that he has legal authority to do so. If patient is a minor or has been adjudicated as a disabled adult, the patient's parent (s) or guardian (s) assumes personal responsibility.

By signing this form, you acknowledge that you have received our “Notice of Privacy Practices” (the “Notice”). This Notice describes in detail how we might use or disclose your protected health information. The Notice also discusses your rights and our duties with respect to your protected health information. You have a right to review the Notice before signing this acknowledgment.

By signing this form, you further acknowledge that medical information collected at Multicare Specialists will be stored in a medical records system and kept securely in line with state and federal regulations.

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