Iagree to pay for services that are not covered or covered charges not paid in full including, but not limited to, any co-payment, co-insurance and/or deductible, or charges that are not covered by my insurance provider or other third party payor. I agree to be responsible for all reasonable attorneys' fees and collection costs resulting from my failure to pay any fees or amounts for which I om financially responsible. I agree that in order for this provider organization and its collection agents to service my account or to collect any omounts I may owe, the provider organization and its collection agents may contact me by telephone at any telephone number, including my cellulor telephone number, that I hove provided to the provider organization and/or ot any telephone number that its collection agents hove obtoined or, ot any telephone number forwarded or transferred from any such telephone number, regarding the services rendered, or my related financial obligations. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. If applicable, data charges and rates from my cellular carrier may apply.
I understond that my protected heolth information may be used and disclosed without my authorization to ollow for treatment, payment, and health care operations os described in the Notice of Privacy Practices. I acknowledge and agree that I hove received a copy of the Notice of Privacy Practices. I understand that the Notice of Privacy Practices may be updated periodically and that a copy of the updated Notice of Privacy Practices will be provided to me upon request.
I understond thot, unless I have requested restrictions in writing, the type of information that this provider organization may release to third parties may include certoin sensitive medicol records including, but not limited to, records regarding psychological treatment, Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV) infections, developmental disabilities, alcoholism, or drug dependence during any period of care and treatment. A form to request restriction of this type of information is available at this location.
CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY.
I understand that it may be necessary for this provider organization and its health core providers to obtoin information regarding prescribed medications that I am currently toking or hove taken in the post for medical care and treatment purposes. I hereby authorize this provider organization and the health care providers to obtain and review my external prescription history from my current and former medical care providers, pharmacies, and drug monitoring agency. This consent helps to facilitate accurate and efficient treatment with minimal inconvenience to you.