Thank you for the opportunity to help you meet your healthcare needs.
Please review; The following financial arrangements will go into effect for patients without insurance coverage.
- COMPLEX CONSULT/ Hospital AdvocacyTelehealth video visit with Dr. Alan F. Bain, D.O. - $427 per hour
- NEW PATIENT COMPLEX CASE CONSULT APPOINTMENTTelehealth video visit with Dr. Alan F. Bain, D.O. - $227 per visit
- PATIENT FOLLOW UP COMPLEX CASE APPOINTMENTTelehealth video visit with Dr. Alan F. Bain, D.O. - $127 per visit
- NEW PATIENT (NON-COMPLEX) CONSULT APPOINTMENTTelehealth video visit with Dr. Alan F. Bain, D.O. - $180-$200
- PATIENT (NON-COMPLEX) FOLLOW UP APPOINTMENTTelehealth video visit with Dr. Alan F. Bain, D.O. - $80 - $100
I authorize the insurance company indicated on this form to pay to the doctor all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the doctor to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether paid by this insurance.
I agree and acknowledge that I am responsible for validating network status with my insurance and Dr. Alan F. Bain, D.O. I understand not all insurance policies cover telehealth visits and I will confirm my plan details prior to my visit.
We understand that sometimes a patient is unable to make a scheduled appointment due to unforeseen circumstances. However, we require patients to reschedule or cancel appointments within 24 hours of a scheduled visit.
Missing your appointment prevents Dr. Alan F. Bain, DO from giving you the care needed. It is also detrimental to others because it prevents us from scheduling another patient who needs care as well. You may call our office at 312-236-7010 x2 or email email@example.com to cancel.
If you are a “no show” or fail to reschedule/cancel an appointment without giving 24 hours’ notice, a $50.00 charge will be applied to your account for each missed appointment.
I have read Chicago Health and Wellness Alliance’s (Office of Dr. Alan F. Bain, DO) self- payment agreement, patient insurance agreement and cancellation agreement in full. I understand it is my responsibility to confirm my insurance eligibility and whether TELEHEALTH is covered with my plan. I understand that any amount that is not covered by my insurance is my responsibility including co-payments, co-insurance, and deductible amounts. I agree to pay any balance left as patient responsibility or as the practice to enroll in a payment plan.
I authorize the above medical practice to process the above credit card as “Card on File” should my account have an outstanding balance.
I understand this authorization will remain in effect until the expiration of the credit card account. Patient may also revoke this form by submitting a written request to the medical practice. Request may be emailed to firstname.lastname@example.org
I, do hereby agree and give my consent to the physician to furnish medical care and treatment considered necessary and proper in diagnosing or treating my physical and mental condition. I understand my physician may utilize a nurse to assist with my plan of care.
I thoughtfully and purposefully allow and encourage Dr. Alan F. Bain, D.O., at his discretion and in compliance with Meaningful Use Attestation and Privacy Rule as set forth by Health Insurance Portability and Accountability Act (1996) under Non-Research Based Information Gathering, to contact directly by all secured means available, all medical personnel, both current and former, that treat, or have treated, me for any medical reason in an attempt to best coordinate and further his understanding of my healthcare goals and parameters.
I am currently utilizing other medical providers and I understand that for Dr. Alan F. Bain, D.O., to make informed medical decisions concerning my care, he must have complete and uncensored access of my medical history and to those individuals that provided me with service.
I understand that for Dr. Alan F. Bain, D.O., to treat and or confer with me about my future/present/former healthcare, he must have unfettered access to my current/former medical records and by my signature below I am authorizing complete access.
I hereby acknowledge and grant Informed Consent, Consent to Contact and Release of My Medical Information, to Dr. Alan F. Bain, D.O., in accordance with generally accepted and prudent medical practices. I will provide Dr. Alan F. Bain, D.O., with names and numbers of all of my current medical providers and, if possible, the names and numbers and or locations of former medical providers, so that he may contact them and discuss their medical findings.
This personally signed consent, or its facsimile, also allows medical providers that have provided me with medical services to disclose documents and talk with Dr. Alan F. Bain, D.O., about their clinical observations and treatment results.
I understand that my records will be kept strictly confidential and that I can discuss with Dr. Alan F.Bain D.O., his findings and request copies of all medical documentation. It is my responsibility to report to Dr.Alan F. Bain D.O., any and all physical concerns I may incur as soon as possible and any changes in my treatment protocol or medication regiment by other medical practitioners.
Introduction Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
Patient medical recordsMedical imagesLive two-way audio and videoOutput data from medical devices and sound and video filesElectronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Improved access to medical care by enabling a patient to remain in his/her provider’s office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.More efficient medical evaluation and management.Obtaining expertise of a distant specialist.
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;By signing this form, I understand the following:
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction and may receive copies of this information for a reasonable fee.I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be in other areas, including out of state.I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
ELECTRONIC COMMUNICATION CONSENT:
I authorize Dr. Alan Bain, D.O., and his practice staff members communicate via email, text and e-message (through the Healow patient portal).
PATIENT CONSENT TO THE USE OF TELEMEDICINE:
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov
We have adopted the following policies:
Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or the doctor.Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.We agree to provide patients with access to their records in accordance with state and federal laws.We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward
The HIPAA Privacy Rule gives individuals a fundamental new right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information. Health plans and covered health care providers are required to develop and distribute a notice that provides a clear explanation of these rights and practices. The notice is intended to focus individuals on privacy issues and concerns, and to prompt them to have discussions with their health plans and health care providers and exercise their rights.
How the Rule Works
General Rule. The Privacy Rule provides that an individual has a right to adequate notice of how a covered entity may use and disclose protected health information about the individual, as well as his or her rights and the covered entity’s obligations with respect to that information. Most covered entities must develop and provide individuals with this notice of their privacy practices.
The Privacy Rule does not require the following covered entities to develop a notice:
Health care clearinghouses, if the only protected health information they create or receive is as a business associate of another covered entity. See 45 CFR 164.500(b)(1). A correctional institution that is a covered entity (e.g., that has a covered health care provider component).A group health plan that provides benefits only through one or more contracts of insurance with health insurance issuers or HMOs, and that does not create or receive protected health information other than summary health information or enrollment or disenrollment information.See 45 CFR 164.520(a).
Content of the Notice. Covered entities are required to provide a notice in plain language that describes:
How the covered entity may use and disclose protected health information about an individual. The individual’s rights with respect to the information and how the individual may exercise these rights, including how the individual may complain to the covered entity.The covered entity’s legal duties with respect to the information, including a statement that the covered entity is required by law to maintain the privacy of protected health information. Whom individuals can contact for further information about the covered entity’s privacy policies. The notice must include an effective date. See 45 CFR 164.520(b) for the specific requirements for developing the content of the notice.
A covered entity is required to promptly revise and distribute its notice whenever it makes material changes to any of its privacy practices. See 45 CFR 164.520(b)(3), 164.520(c)(1)(i)(C) for health plans, and 164.520(c)(2)(iv) for covered health care providers with direct treatment relationships with individuals.
Providing the Notice.
A covered entity must make its notice available to any person who asks for it. A covered entity must prominently post and make available its notice on any web site it maintains that provides information about its customer services or benefits. Health Plans must also:Provide the notice to individuals then covered by the plan no later than April 14, 2003 (April 14, 2004, for small health plans) and to new enrollees at the time of enrollment.Provide a revised notice to individuals then covered by the plan within 60 days of a material revision.Notify individuals then covered by the plan of the availability of and how to obtain the notice at least once every three years.Covered Direct Treatment Providers must also: Provide the notice to the individual no later than the date of first service delivery (after the April 14, 2003 compliance date of the Privacy Rule) and, except in an emergency treatment situation, make a good faith effort to obtain the individual’s written acknowledgment of receipt of the notice. If an acknowledgment cannot be obtained, the provider must document his or her efforts to obtain the acknowledgment and the reason why it was not obtained.When first service delivery to an individual is provided over the Internet, through e-mail, or otherwise electronically, the provider must send an electronic notice automatically and contemporaneously in response to the individual’s first request for service. The provider must make a good faith effort to obtain a return receipt or other transmission from the individual in response to receiving the notice.In an emergency treatment situation, provide the notice as soon as it is reasonably practicable to do so after the emergency situation has ended. In these situations, providers are not required to make a good faith effort to obtain a written acknowledgment from individuals. Make the latest notice (i.e., the one that reflects any changes in privacy policies) available at the provider’s office or facility for individuals to request to take with them and post it in a clear and prominent location at the facility. A covered entity may e-mail the notice to an individual if the individual agrees to receive an electronic notice. See 45 CFR 164.520(c) for the specific requirements for providing the notice. organizational Options. Any covered entity, including a hybrid entity or an affiliated covered entity, may choose to develop more than one notice, such as when an entity performs different types of covered functions (i.e., the functions that make it a health plan, a health care provider, or a health care clearinghouse) and there are variations in its privacy practices among these covered functions. Covered entities are encouraged to provide individuals with the most specific notice possible.Covered entities that participate in an organized health care arrangement may choose to produce a single, joint notice if certain requirements are met. For example, the joint notice must describe the covered entities and the service delivery sites to which it applies. If any one of the participating covered entities provides the joint notice to an individual, the notice distribution requirement with respect to that individual is met for all the covered entities. See 45 CFR 164.520(d).