Warning: This form will time out if not completed in one sitting.

I do hereby consent to any medical care which is deemed advisable or necessary by my healthcare provider and grant authority to Badia Hand to Shoulder Center,to administer and perform all examinations, treatments, diagnostic procedures and surgeries needed now or in the future. I guarantee payment for all services rendered. All medical benefits including major medical benefits, private insurance, and any other health plan, are assigned to Badia Hand to Shoulder Center. The signaturebelow confirms all of the information provided herein is true and accurate. Photocopy of this consent is to be considered as valid as the original.

This is an agreement between Badia Hand to Shoulder Center, as creditor, and the Patient/Debtor named on this form.

 

Insurance: Insurance is a contract between you and your insurance company. It is your responsibility to understand your insurance plan benefits. In order to file your claims, we require a legible copy of the front & back of the insurance card, photo ID, social security number and verification of benefits by your insurance company prior to visits. It is the responsibility of the insured/patient to supply current and accurate information including primary and secondary insurance for claims submissions PRIOR to receiving services. All copay, coinsurance and deductibles are due at the time services are rendered.

 

Failure to provide complete and accurate insurance information may result in the entire bill being your responsibility. Although we estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. Once the claim is processed, if there is any additional liability, you will be billed accordingly.

 

Services unexpectedly denied by your insurance plan due to retroactive terminations, Coordination of Benefits (other health insurance that may be primary) denials, payment offset due to retroactive termination, failure to respond to your insurance plans with requested information or failure to provide our office with any new health insurance changes are all reasons patients may be responsible for payment of services received in our office. All of these circumstances are beyond our control. It is the patient's responsibility to resolve any issues that arise with their eligibility and benefits.

 

If you are covered by a plan that we are not participating providers for, payment is expected when services are rendered. We will provide you with an itemized receipt for you to file with your insurance. Your insurance company will be responsible for reimbursing you for any coverage you may have. We highly recommend you contact your insurance carrier and check your available benefits before care is received from our office. Do not assume that you will not owe anything, even if you have more than one insurance policy.

 

Self-pay accounts: Self pay accounts are patients without insurance coverage, patients covered by insurance plans in which the office does not participate, or patients without an insurance card on file with us. It is always the patient's responsibility to know if our office is participating with their plan. If you have health insurance and there is a discrepancy regarding your coverage or eligibility, the patient will be considered self-pay unless otherwise proven.

 

Appointment Cancellation Policy: If you need to cancel your appointment, please notify our office at least 24 business hours in advance. Failure to do this keeps us from scheduling other patients that need to be seen. A fee will be charged for appointments not cancelled with 24 hours advanced notice. This includes cancelled appointments, rescheduled appointments, and missed appointments (no-shows The fee for this is $50.00. This fee will have to be paid at the time of your rescheduled appointment; if no appointment is rescheduled, you will be billed for this fee. The provider will not see you until this fee has been paid.

 

Collection fee: A fee totaling 30% of the balance due will be added to your account if we have to send your account to a collection agency. You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account to any credit reporting agency such as a credit bureau.

 

Waiver of confidentiality: You understand that if this account is submitted to an attorney or collection agency, if we must litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

 

Disability forms, insurance forms, and other forms: There will be a fee of $75.00 for the completion of medical forms. Payment is due at the time the form is dropped off. Please allow 5-7 business days for these to be completed.

 

Copying of records: There is a fee of $1/page for the first 25 pages and 25 cents for every page thereafter for copies of your records to be sent to another doctor or organization. You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history. Copies of images (x-ray, MRI) are available by CD and are subject to a $10.00 fee per disc.

Acknowledgement of Privacy Practices

I hereby acknowledge that I have received a copy of Badia Hand to Shoulder Center Notice of Privacy Practices as required by federal law.

 

Patient Consent for use and disclosure of Protected Health Information

I authorize the office Badia Hand to Shoulder Center to disclose protected health information to the following:

 

Telephone Messages:

Consent to photograph

I authorize Badia Hand to Shoulder, LLC and its affiliates to take pictures of my (or my child's) medical or surgical procedure(s) and condition(s) and to the use of such pictures for treatment, scientific, educational or research purposes.

By signing below, I certify that I have read, understand, and agree to all four Notices above.

Mutual Agreement

 

Dr. Alejandro Badia, M.D., and Badia Hand to Shoulder Center (collectively labeled "physician") agree to provide treatment to:_________________("patient")

 

The Physician takes pride in being able to extend a greater degree of privacy than is required by law.

 

Federal and State privacy laws are complex. Unfortunately, some medical offices try to find loopholes around these laws. For example, physicians are forbidden by law from receiving money for selling lists of patients or medical information to companies to market their products or services directly to patients without authorization. Some medical practices, though, can lawfully circumvent this limitation by having a third party perform the marketing. While personal data is never technically in the possession of the company selling its products or services, the patient can still be targeted with unwanted marketing information. Physician believes this is improper and may not be in the patient's best interest. Accordingly, Physician agrees not to provide medical information for the purposes of marketing directly to Patient. Regardless of legal privacy loopholes, Physician will never attempt to leverage its relationship with Patient by seeking Patient's consent for marketing products for others.

 

Patient and Physician acknowledge that breach of this Agreement may result in serious, irreparable harm. Patient and Physician agree to the right of equitable relief (including but not limited to injunctive relief Should a breach of this Agreement result in litigation, the prevailing party in the litigation shall be entitled to reasonable costs, expenses, and attorney fees associated with the litigation.

 

Agreement as to Resolution of Concerns

 

"I", "Patient/Guardian" shall be understood to mean _______________

 

."Physician" shall be understood to mean Alejandro Badia, M.D. / Badia Hand to Shoulder Center.

 

Further, I understand that I am entering into a contractual relationship with Physician for professional care. I further understand that meritless and frivolous claims for medical malpractice have an adverse effect upon the cost and availability of medical care, and may result in irreparable harm to a medical provider. As additional consideration for professional care provided to me by Physician, I, the patient/guardian and/or my representative agrees not to advance, directly or indirectly, any false, meritless, and/or frivolous claim(s) of medical malpractice against Physician.

 

Furthermore, should a meritorious medical malpractice cause or cause of action be initiated or pursued, I and/or my representative agree to use American Board of Medical Specialties ("ABMS") board-certified expert medical witness(es) in the same specialty as Physician. Furthermore, I agree that these witnesses will be members in good standing of, and adhere to the guidelines and/or code of conduct, defined for expert witnesses by the ASSH and AAOS.

 

In further consideration for this, Physician agrees to the same stipulations. Patient/guardian and Physician acknowledge that monetary damages may not provide an adequate remedy for breach of this Agreement. Such breach may result in irreparable harm to Physician's reputation and business. Patient/guardian and Physician agree in the event of a breach to allow specific performance and/or injunctive relief.

Medications:

Please list all medications you take on a regular basis