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Updated Patient Information and Insurance
Due to recent federal privacy guidelines (HIPAA), Neurology Institute of Huntsville, Inc is not allowed to release information to anyone other than the patient (or guardian of the patient) unless there is explicit authorization given to authorize Neurology Institute of Huntsville Inc. permission to discus personal medical information with someone other than the patient or guardian of the patient. Please ill this form in order to allow us to discuss your information with the people of your choosing as listed below.
I blanks* give Neurology Institute of Huntsville permission to release/ discusspersonal health information, which includes the pick up of prescriptions and/or financial information to/with:
Name: First Name Last Name Phone: blanksRelationship: blank
Name: First Name Last Name Phone: blanks Relationship: blank
Name: First Name Last Name Phone: blanksRelationship:blank
Name: First Name Last Name Phone: blanks Relationship: blank
I understand that I may revoke this authorization at any time by sending a written notification to Neurology Instituteof
Huntsville. By signing this form, all previous lists of allowable contacts become invalid.
I blanks decline to give Neurology Institute of Huntsville Inc. permission to release/ discuss my personal health and/or financial information to anyone other than myself.
ASSIGNMENT OF BENEFITS, AGREEMENT, AND GUARANTY
I authorize Neurology Institute of Huntsville Inc (NIH) to release any information regarding services rendered to me to third party payers in consideration of payment for my care or to other healthcare providers involved in my care. I understand payment of all insurance benefits, basic and major medical for this period of service must be made directly to NIH. If the check must be made out to me, I understand the check must be sent to this address: 2006 Franklin St. Suite 202A, Huntsville, AL 35801. I understand that NIH must collect for all charges not covered by insurance payments. Payment for all collection costs, ssecuring, or attempting to collect necessary otherwise is the financial responsibility of the patient or guardian. Patients who are considered a legal adult are financially responsible for all services rendered.
I understand that the following authorizations are to be used by Neurology Institute of Huntsville, Inc. and all the physicians associated therewith to affect the collections on my behalf. These authorizations become effective on the date of the first service rendered on my behalf and remain in effect until specifically revoked in writing by me. Copies of this agreement will be valid as this original.
I understand that the patient portal is mandatory. I will receive access to this account to view my labs, notes, and imaging that are ordered by the practice. If there are any questions regarding this, I may contact the practice to schedule a follow up appointment. Practice will not be liable for any delay in results as well as abnormal results, if I decide to not obtain access
NIH NOTICE OF PRIVACY PRACTICES AND ACKNOWLEDGEMENT
I acknowledge that a copy of the Notice of Privacy Practices for NIH has been made available to me. In connection with the notice, I also acknowledge that I have been provided with an opportunity to ask any questions regarding the notice and its contents.
EXPRESS PERMISSION TO CONTACT PATIENT BY CELL PHONE
I agree in order for NIH to service my account or collect monies I owe NIH their/our agents may contact me by any telephone number associated with my account, including wireless telephone numbers, which can result in charges to me. NIH may also contact me by sending text messages or emails, using any email address I provided. Methods of contact may include pre-recorded/artificia voice messages and/or use of automatic dialing divides as applicable. I have read this disclosure and agree that NIH, its employees, and/or agent may contact me as described above.
Please Select Information to be Disclosed:
I understand that I may revoke this authorization at any time by giving written notice of my revocation to the address listed above. I understand that revocation of this authorization will not affect any action taken in reliance on this authorization before they received my written notice of revocation.
By signing this authorization, I hereby authorize the entities listed above to disclose my personal health information. I understand that information contained in my PHI may include information related to sexually transmitted disease(s) acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. By signing this authorization, I understand that my PHI described herein may be disclosed by the entities above to receive and use my PHI and that my PHI described herein may no longer be protected by federal privacy regulations.
1. Care shall be provided impartially without regard to race, creed, sex, or national origin.
2. Patients are entitled to considerate, respectful, and dignified care at all times.
3.The patient has the right to receive care in a safe setting.
4.Patients are entitled to personal and informational privacy as required by law. This includes the right to:
5.Patients and/or patients legally designated representatives have the right of access to information contained in the patient's medical record, within the limits of the law and in accordance with NIH policies.
6.Patients of NIH have the right to know the identity and professional status of all persons participating in their
7.Patients are entitled to know the status of their condition including diagnosis, recommended treatment and prognosis for recovery.
8.Patients have the right to be free from physical restraints which are not medically indicated or necessary.
9.Patients have the right, in collaborating with their physicians to make decisions involving their health care, including acceptances or refusal of medical care or treatment to the extent permitted by law and to be informed of the medical consequences of such refusal.
10. Patients are entitled to formulate advance directives and appoint a surrogate to make healthcare decisions on their behalf of the extent permitted by law.
11. Patients are entitled to receive an itemized detailed explanation of charges related to services rendered ontheir behalf.
12. Patients will not be transferred to another facility or location without explanation of the necessity of such
13. A patient's guardian, next of kin, or legally authorized responsible person may exercise, to the extent permitted by law, the rights delineated on behalf of the patient if the patient has been judged incompetant in accordance with the law, or procedure, or is unable to communicate his/her wishes regarding treatment, or is a minor.
14. Patients have the right to appropriate assessment and management of pain.
15. Patient have the right, subbjext to the patient's consent, to receive visitors whom they designate, including, but not limited to, a spouse, domestic partner (including same-sex domestic partner), anothe rfamily memeber, or a friend. Patients have the right to withdraw or deny any such consent at any time.
16. Ents are responsible for providing NIH with complete and accurate information regarding present and past illnesses and operations, hospitalizations, medications, and other health related issues, including any unanticipated changes in their condition.
17. Patients are responsible for following recommended treatment plans prescribed and/or administration.
18. Patients who refuse prescribed treatments or do not follow their practitioner's instructions assume full responsibility for the consequences of such actions.
19. Patients are responsible for ensuring prompt and complete payment of their account at NIH.
20. All patients must follow NIH rules and regulation relative to patient care and conduct. This includes consideration and respect for the rights and property of other patients and NIH providers and statt, as well as responsibility for the actions of their visitors and guests.