CONSENT TO TREAT: The undersigned consents to any initial or follow-up evaluations, examinations, x-rays, laboratory procedures, other tests, medications, medical treatment, surgery, physical therapy, home instructions, orthotics, other durable medical equipment, photographing and/or videotaping and/or other services rendered to the patient by INSTRIDE FOOT & ANKLE SPECIALISTS, LLC and its providers. The undersigned agrees that it is their responsibility to schedule any follow up visits, other services, prescriptions and items ordered for the patient. Some physicians of INSTRIDE FOOT & ANKLE SPECIALISTS, LLC may benefit financially from an ownership interest in pathology services. Because of this ownership interest, you have the right to choose a different pathology provider, and we will make such arrangements upon your request. The undersigned also understands that providers exercise their care with reasonable skill and diligence, but make no guarantee as to the results or cure that will be attained.
DIGITAL E-PRESCRIBING: I authorize INSTRIDE FOOT & ANKLE SPECIALISTS, LLC and its associates to view my external prescription history via electronic e-prescribing services. I understand that prescription history from multiple, other unaffiliated, providers, insurance companies, pharmacies and pharmacy benefit managers may be viewable by the providers and staff of INSTRIDE FOOT & ANKLE SPECIALISTS, LLC and it may include prescriptions back in time for several years and may include prescriptions to treat HIV, substance abuse and psychiatric conditions. If applicable, I understand that my prescription history will become part of my record at this practice. I understand all of the above, I hereby provide informed consent to INSTRIDE FOOT & ANKLE SPECIALISTS, LLC to enroll me in the e-prescribe program. This consent will remain enforced until revoked or changed.
ASSIGNMENT OF BENEFITS: I hereby irrevocably assign, transfer and convey to INSTRIDE FOOT & ANKLE SPECIALISTS, LLC and any practitioner providing care and treatment to me/my dependent, any and all benefits and all interest and rights (including causes of action, the right to enforce payment and the right to appeal an adverse benefit determination) to which I am entitled under an employee benefit plan sponsored by my employer, all insurance policies, benefits, any third-party reimbursement, or prepaid health care plan for services rendered or products I received from INSTRIDE FOOT & ANKLE SPECIALISTS, LLC.
MEDICARE ASSIGNMENT: I certify that the information given by me in applying for payment under XVIII of the Social Security Act is correct and agree to complete the Medicare screening form annually. I authorize the release of information concerning me to the Social Security Administration or its intermediaries as well as any information needed for filing a Medicare claim; I request that payment and authorized benefits be made on my behalf. I assign benefits payable for services to INSTRIDE FOOT & ANKLE SPECIALISTS, LLC.
AUTHORIZATION TO RELEASE INFORMATION: I consent and authorize INSTRIDE FOOT & ANKLE SPECIALISTS, LLC and its agents to release my health information for the purpose of payment, treatment, and healthcare operations to any of the following: insurance company and its affiliates, any practitioner, support staff or facility involved in my plan of care or transfer of care. In addition I understand that the potential uses and disclosures of my Health Information are detailed in the Privacy notice. The HIPAA Notice of Privacy Practices are available online. Individual copies are also available in the office and posted in the lobby. I have read/had the opportunity to read my HIPAA rights, which include fees for records.
DESIGNATION OF AUTHORIZED REPRESENTATIVE: I designate and appoint INSTRIDE FOOT & ANKLE SPECIALISTS, LLC (and its agents) as my authorized representative and authorize it to act on my behalf to 1) request and receive a copy of the summary plan description, 2) pursue a benefit claim, 3) appeal any adverse benefit determination, and/or 4) file a legal/equitable action to recover benefits from my employee benefit plan, insurance policy, and any third-party reimbursement or prepaid health care plan. I understand and agree that my authorized representative shall have full authority to act, and receive notices, on my behalf with respect to an initial determination of the claim for health benefits relating to treatment and health care services received by me/my dependent at INSTRIDE FOOT & ANKLE SPECIALISTS, LLC, any requests for documents relating to this claim and appeal of an adverse determination of the claim.
FINANCIAL AGREEMENT: I hereby promise to pay for all products received or services rendered to me/my dependent to the extent I am legally responsible for such payment. I understand that I am responsible for all health insurance copayments, deductibles, coinsurances, OTC (over the counter) convenience items and NCS (noncovered services) and any other amounts that apply at the time of service or at the pre-operative appointment. Regardless of the assignment of benefits, should the insurance misrepresent their coverage or delay payment of a claim greater than 60 days, as the designated responsible party, I am responsible for all monies owed to INSTRIDE FOOT & ANKLE SPECIALISTS, LLC. I also understand that the insurance policy is a contract between me and the insurance company; therefore the policy holder should contact the insurance carrier first when there are questions regarding an explanation of benefits.
CONSENT FOR PHOTOGRAPHY: I authorize INSTRIDE FOOT & ANKLE SPECIALISTS, LLC to take photographs during the course of my treatment. I understand that the media is the property of INSTRIDE FOOT & ANKLE SPECIALISTS, LLC, and I may obtain a copy upon my written request. I agree and authorize the use of the media in my medical record and for teaching purposes, which includes being shown to other patients. I am aware that my name and identity will not be disclosed.
CONSENT FOR COMMUNICATION: I authorize INSTRIDE FOOT & ANKLE SPECIALISTS, LLC, and its associates to contact me by telephone at any phone number associated with my account, including wireless telephone numbers, which could result in charges to me. INSTRIDE FOOT & ANKLE SPECIALISTS, LLC, and its associates may also contact me by sending text messages or emails, using any email address you provide us to use. Methods of contact may include using pre-recorded or artificial voice messages and/or use of an automatic dialing device, as applicable.
PRIVACY NOTICE: I understand that INSTRIDE FOOT & ANKLE SPECIALISTS, LLC may use and disclose my protected health information for purposes of treatment, payment, and health care operations. We may use your protected health information for our own health care operations and for those of the Organized Health Care Arrangements in which we participate. I also acknowledge that I have received, have been offered to read the notice at www.instridefoot.com, or have received in the past a copy of the Practice’s Notice of Privacy Practices, which provides information about how the practice, and individuals involved in my care in the practice, may use and disclose my protected health information. As provided in the notice, the terms of the notice may change. To obtain a copy of any current notice, contact the privacy office at INSTRIDE FOOT & ANKLE SPECIALISTS, LLC.
I understand that I have the right to request that the practice restrict how my protected health information is used or disclosed for treatment, payment or health care operations, but I also understand that the practice is not required to agree to a requested restriction. However, if the practice does agree, it is bound by that agreement. I understand that I have the right to revoke this consent in writing at any time, except to the extent that the practice, or individuals involved in my care in the practice, have already used or disclosed protected health information in reliance on my prior consent.