Acknowledgement and Authority

I consent to treatment from April Carlton or any of her associated partners,
as necessary or desirable for the care of the patient named on the form. This including, but not restricting to any drugs, medications, lab tests or other studies which may be used by the physician of his/her qualified, designated associate practitioners practicing at her office. I acknowledge full responsibility for payment of such services and agree to pay my bill in full at the time of service.

I understand that insurance coverage is an arrangement between the insurance carrier and the patient. Carlton Family Practice, as a courtesy to me, will assist in
billing my insurance company, but I am ultimately responsible for the payment should my insurance fail to pay within a reasonable period of time.

I authorize April Carlton, APRN to release information as required to my insurance or third party payer (including my employer or worker compensation carrier) for the purpose of determining benefits.

I understand that such records may include information regarding having
HIV/AIDS testing, substance abuse and/or mental health issues. I also authorize Carlton Family Practice to bill my insurance or third party payer and receive payment directly from them for services rendered. 

The authorization shall remain valid until I revoke it in writing. A photocopy or a faxed copy of this authorization shall be deemed as valid as the original.

Written Acknowledgement of Receipt of Notice of Privacy Practices

You acknowledge receiving the Carlton Family Practice Notice of Privacy Practice
(“Notice”). The Notice explains how Carlton Family Practice may use and disclose your protected health information for treatment, payment, and health care operation purposes. “Protected Health Information” means your personal health information found in your medical and
billing records.

Carlton Family Practice reserves the right to change the Notice from time to time. A copy of the current Notice or a summary of the current Notice will be posted at patient service locations throughout Carlton Family Practice and on our website carltonfp.com. The effective date of the Notice will appear on the first page of the Notice or summary. In addition, Carlton Family Practice will have available for you, at your request, a copy of the current Notice in effect.

 

AUTHORIZATION

I Authorize CARLTON FAMILY PRACTICE TO USE AND DISCLOSE THE PROTECTED HEALTH INFORMATION DESCBRIBED TO (INDUVIDUAL SEEKING INFORMATION)

EFFECTIVE PERIOD

This authorization for realease of information covers the period of healthcare 

From:

OR

This medical information may be used by the persons I authorize to receive this information for my medical treatment or consultation, billing, or claims payment, or other purposes as I may direct.

This Authorization shall be in force until and in effect until I notify CFP to stop.

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation in not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurnance coverage and the insurer has a legal right to contest a claim.

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this Authorization.

I understand that information used or Disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. 

Our offices are compliant with the laws & regulations regarding the Privacy of Protected Health Information (PHI). Please review our HIPPA Notice of Privacy Practices. We also require patients to give consent to receive healthcare services from our Provider(s) at Carlton Family Practice, LLC and/or AR Journey Lab, LLC.
For Carlton Family Practice, LLC and/or AR Journey Lab, LLC to disclose to another person your Protected Health Information (PHI) please read, complete, and sign these forms.

You have a right to receive a copy of this form.

General Consent to Treat

1. I voluntarily consent to all health care treatment and diagnostic procedures provided by Carlton Family Practice, LLC and/or AR Journey Lab and its associated physicians, clinicians, and other personnel. I am aware that the practice of medicine and other healthcare professions is not an exact science and I further
state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at Carlton Family Practice, LLC and/or AR Journey Lab, LLC.

2. I consent to the use and disclosure of my/the patients PHI for purposes of obtaining payment for services rendered to me/the patient, treatment, and health care operations consistent with the Carlton Family Practice, LLC and/or AR Journey Lab, LLC Notice of Privacy Practices.

3. I authorize payment of medical benefits to Carlton Family Practice, LLC and/or AR Journey Lab, LLC or their designee for services rendered

4. I give permission to obtain all of my medical/prescription history when using an electronic system to process prescriptions for my medical treatment.

5. If I am an eligible Medicare Patient, I agree to Medicare’s Chronic Care Management services.

 

Telehealth Consent to Treat

1. I hereby authorize Carlton Family Practice, LLC to use the telehealth practice platform for telecommunication for evaluating, testing, and diagnosing my medical condition

2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended

3. I accept that the professionals can conduct interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met

4. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover

5. I agree that my medical records on the telehealth can be kept for further evaluation, analysis, and documentation, and in all these, my information will be kept private.

The following notice describes how medical information about you may be used, disclosed, and how you can get access to this information.

Special Situations that DO NOT require your permission

We may be required by law to report gunshot wounds, suspected abuse, or neglect, and so on; we may be required to disclose vital statistics, diseases, and similar information to public health authorities; we may be required to disclose information for audits and similar activities, in response to a subpoena or court order, or as
required by law enforcement officials. We may release information about you for workers compensation or similar programs to protect your health or the health of others or for legitimate government needs, for approved medical research, or to certain entities in the case of death. Your PHI may also be shared if you are an inmate or under custody of the law which is necessary for your health or the health and safety of other individuals

Military Activity and National Security

When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel for activities deemed necessary by appropriate military command authorities, for the purpose of a determination by the Department of Veteran Affairs of your eligibility for benefits, or to foreign military authority if you are a member of that foreign military services. In some situations, we may ask for your written authorization before using or disclosing any identifiable health information about you. If you sign an authorization, you can later revoke
the authorization.

Individual Rights

You have certain rights regarding your PHI, for example: unless you object, we my share your PHI with friends or family members, or other persons directly identified by you at the level they are involved in your care or payment of services. If you are not present or able to agree/object, the healthcare provider using professional judgement will determine if it is in your best interest to share the information. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. We may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts. You may request restrictions on certain uses and disclosures of your PHI. We are not
required to accept all restrictions. If you pay in full for a treatment or service immediately, you can request that we not share this information with your medical insurance provider or our Business Associates. We will make every attempt to accommodate this request and, if we cannot, we will tell you prior to the treatment. 

You may ask us to communicate with you confidentially by, for example, sending notices to a special address. In most cases, you have the right to get a copy of your PHI. There will be a charge for the copies. If you believe information in your record is incorrect or if important information is missing you have the right to request that we amend the existing information by submitting a written request. You may request a list of operations. The first request in a 12-month
period is free; there will be charges for additional reports. You have the right to obtain a written copy of this Notice from us, upon request. We will provide you a copy of this Notice on the first day we treat you at our facility. In an emergency we will give you this Notice as soon as possible. You have the right to receive notification of any breach of your PHI

Our Legal Duty

We are required by law to protect and maintain the privacy of your PHI, to provide this Notice about our legal duties and privacy practices regarding PHI, and to abide by the terms of the Notice Currently in effect. We may update or change our privacy practices and policies at any time. Before we make a significant change in our policies, we will change our Notice and post the new Notice on our website at
www.carltonfp.com. You can also request a copy of our Notice at any time. If you are concerned about your privacy rights, or if you disagree with a decision we made about your records, you may contact the Privacy Officer listed below. You may also send a written complaint to the U.S. Department of Health
and Human Services. You will not be penalized in any way for filing a complaint.

Contact Information

If you have any questions, requests or complaints, please contact:

Carlton Family Practice, LLC
Attn: April Carlton, APRN
3111 Military Rd
Benton, AR 72015
Email: acarlton@carltonfp.com
Phone #: 501-507-0710
HIPPA
US DHHS
Atlanta Federal Center
Suite 3B70 61 Forsyth Street
Atlanta, GA 30303-8909

Financial Policies & Disclosures

 

Indenmification Clause

I agree to indemnify, defend, protect, and hold harmless the Medical Providers employed Carlton Family Practice; and their resprective officers, Directors, Employees, Stockholders, Assigns, Sucessors and Affiliates (Indemnified Parties) from, against and in respect of all Liabilities, Losses, Claims, Damages, Judgements, Settlement Payments, Deficiencies, Penalties, Fines, Interest and Costs, Expenses Suffered, Sustained, Incurred or paid by the Indemnified Parties, in connection with, results from or arising out of, diretly or indirectly, the Medical Providers employed by Carlton Family Practice; rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and phyisical condition, acts of omissions, the medical providers employed by Carlton Family Practice; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the Medical Providers employed by Carlton Family Practice. I am aware of the potential side effects associated with Medical Care and Weight Loss Therapy and accept all the risks involved in taking the medication and will not seek indemnification or damages from the Indemnified Parties. 

The Financial Policy and Disclosure is to help us provide the most effective and reasonable health care services. Therefore, it is necessary for us to have a Financial Policy and Disclosure stating our requirements for payment for services provided to patient. Patients are responsible for payment of all services provided by Carlton Family Practice. LLC and their associates.

Self-Pay Policies

If you are a Self-Pay patient, you will be required to pay for the office visit before services are rendered and any labs ordered will be paid directly to AR Journey Lab, LLC. In addition, any remaining balance on your account will be collected at discharge.

Insurance Policies

If you are an insurance patient, it is our policy to file for insurance as a courtesy to you, if we have accurate and complete insurance information. If a service is provided that is not covered by your insurance company, you will be the
responsible party at the time of the service. If we have not received a payment from your insurance company within thirty (30) days, you will be responsible for the balance due.

Deductibles, co-payments, and coinsurance will be collected before services are rendered. In special cases, we may need your help in contacting your insurance company for the payment of your services.

Workers Compensation Policies 

If you are a workers compensation patient, it is our policy to bill your employer or the workers compensation carrier for services rendered. If you are covered under worker’s compensation, we will accept the payments by the worker’s compensation carrier as per contracted rates based on the mandated AR state fee schedule.
If payment is denied from your worker’s compensation carrier, you will become
responsible for the entire balance of your services. Payment will be due withing ten (10) days following any worker’s compensation payment denial.
It will be your responsibility to contact us with the name and address of your employer or the insurance company that covers your employer.

X-Ray Policies

Iif you require an x-ray on todays visit, the x-ray will be sent out to a Radiologist for a second opinion for quality assurance purposes.
You will be responsible for the cost of this service if your insurance company chooses not to cover it

Overdue & Credit Balance Policies

All over-due patient balances will be sent to collections. All accounts sent to collections will be charged a $25 collection fee in addition to the account
balance.

Credit balances under $15 aged over 60 days may be written off

Divorce and/or Custody Case Policies

The parent or guardian who brings the patient into our office will be held financially responsible regardless of the provisions in the divorce decree or who has custody or who has the insurance.

To help Carlton Family Practice, LLC and AR Journey Lab, LLC to adhere to our policies as outlined
above, we ask that you assist us by: 

1. Providing us with current and updated information on yourself and your insurance company

2. Presenting an updated photo identification card and insurance card when changes are made 

3. Making the appropriate payment at the time of service, whether it is deductible, co-pay, coinsurance, or the full amount if you are a Self-Pay Patient.
Patient Health Information (PHI) Consent Form Financial Policy & Disclosures
By signing this form, you are giving consent to services and have read & initiated the above terms and conditions.

No Call - No Show Patients

For patients who are registered for an appoint and do not provide notice to our office that they will not be present for their scheduled appointment there will be

A $25.00 FEE

billed to the patient via text or email address on file.

You may elect for us to release your HIPPA Information. IF you would like for use to share your information, please let us know who you would like for us to release your records to. 

Who would you like to have access?