Consent for Treatment I give my consent to Pinnacle Behavioral Healthcare (PBH) providers to examine, treat and perform tests, and to give me such medications as they believe are necessary or advisable.
Consent to Release Information I understand that protected health information may refer to medical or health information, including prognosis, psychological or mental illness, prescription, laboratory, and other medical results, including HIV tests or diagnosis. I give my consent for the release of my protected health information for the purpose of treatment, payment, and other relevant health care operations. I hereby authorize the medical facility to use my medical information for their exercise of rights, title, and interest in the payment from healthcare insurance services or third-party payors, including but not limited to Medicare, insurance, among others for which are only covered by them. I understand that there are certain procedures and/or treatments that may not be covered or partially covered by healthcare insurance services. In this case, I understand that I shall be financially responsible and may receive a separate billing for the procedures taken.
Personal Property Responsibility I understand that PBH is not responsible for the loss of valuables such as teeth, glasses, hearing aids, jewellery, watches, radio, wheelchairs, walkers, prosthetic devices, etc. PBH assumes no responsibility for their loss.
Right To Revoke I understand that I have the right to revoke any of the above consents at any time through written notification to PBH.