I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain privacy rights regarding my protected health information. I acknowledge that I have received or have been given the opportunity to receive a copy of Saugatuck Pediatrics’ Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices.
I understand that federal law permits Saugatuck Pediatrics to use my protected health information (“PHI”) for a variety of purposes including, but not limited to, treatment, to obtain payment, for healthcare operations, and when required by law for public health purposes. I understand that Saugatuck Pediatrics may need to contact my guarantor (person responsible for payment of medical bills) and/or the policy holder for my insurance to exchange information, when necessary for the purpose of obtaining payment. By signing this form, I acknowledge and consent to these practices.
I understand that I am ultimately responsible for payment of my medical bills. I agree to pay all copays and charges not covered by my insurance. In addition, the following person is delegated responsibility for my medical bills (guarantor; usually a parent whose insurance policy covers me) and may communicate with Saugatuck Pediatrics LLC about bills: