Achieving a Strong Patient-Provider Team Partnership
We value the relationships we build with our patients. Building this partnership between you and your provider team begins with mutual trust and respect.
You can expect us to:
- treat you with courtesy and respect, both in the office and on the phone
- respect your personal, religious, and cultural beliefs
- protect your privacy and ensure your dignity
- respect your individual needs and wishes and meet them as much as we reasonably can
- work together as a team to create the best treatment plan for you
- make every effort to meet your needs in a timely way, while following our policies and procedures
We expect you to:
- treat all staff and visitors with courtesy and respect, both in the office and on the phone
- keep your voice low enough that only the person you are speaking with can hear. This also keeps your protected health information private
- do your best to follow the treatment plan that you and your health care team have created
- let the team know if you have trouble following that plan
Financial Responsibility Agreement and Assignment of Benefits
- I authorize Greater Seacoast Community Health to bill and receive payment from my insurance company for services rendered.
- I understand that I am financially responsible for all charges incurred that are not covered by my or my child's insurance company, including but not limited to deductibles and co-payments.
- I authorize the release of Personal Health Information necessary to file a claim and audit with my insurance company and assign benefits to the provider or group indicated on the claim.
Please read these three documents, which are available upon request from office staff and also at GetCommunityHealth.org/patient-info/
- Patients Notice of Privacy and Use and Disclosure of Health Information
- Patient Rights and Responsibilities in a Patient-Centered Medical Home
- Financial Policy
I understand the information contained in this Informed Consent document. I agree to the conditions set forth in the Informed Consent and in the other documents referenced above. Any questions I had about this consent have been answered. This consent will remain in effect unless I revoke it in writing, which I may do at any time.