PATIENT REGISTRATION FORM

If the patient is responsible for his/her bill, please skip the next section.

The guarantor is the person responsible for the patient’s bill. If the patient is a minor (under the age of 18), the parent or guardian bringing the patient to the visit is usually the guarantor for the patient.

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I amfinancially responsible for any balance. I also authorize LibertyMed Health or insurance company to release any information required to process my claims.

Thank you for choosing us as your health provider. Good care for you and your family starts with good communication, and we have created this policy to help our patients understand their financial responsibilities. If at any time you have questions, please ask us.
Please sign below after reading this policy. A copy will be provided to you upon request

1. Payment for service. Payment is due during service unless other arrangements have been made. We gladly accept major credit cards, including Amex, Visa, MasterCard, Discover, and personal checks or cash. Ask us about other financial arrangements available. ALL IN OFFICE MEDICAL SUPPLY SALES ARE FINAL AND NON-REFUNDABLE.
2. Insurance Coverage. We participate in most major insurance plans. If you are not insured by a plan that we are a provider for, payment in full is expected at each visit. If you are insured by a plan we do business with but need an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility.
   Please contact your insurance company with any questions regarding your coverage.
   a. Proof of insurance. All patients must complete our patient information form before seeing the doctor. To confirm your insurance eligibility, please provide us with a copy of your driver's license and current valid insurance. If you fail to promptly provide us with the correct insurance information, you may be responsible for the balance of the claim.
   b. Coverage changes. If your insurance changes, please notify us immediately so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance may automatically be billed to you.
3. Out-of-Pocket Responsibility: Sometimes, our fees may be adjusted based on whether we participate in or accept insurance or government program payments, allowances, or limitations. But, if we present a charge to you, it means that we have taken any
   such adjustment into account and that you must still pay the amount remaining. If you are reimbursed directly by a program for the cost of your care, you must still pay our charges promptly, whether or not you have received that reimbursement. If you do not agree with patient responsibility or reimbursement amounts set by your insurance or government program, this is a matter between you and that program. We are happy to provide you with factual information about your care and billing to help you discuss this with them, but we still require you to promptly pay the entire charge we present to you, even if your issue with the program is not resolved.
   a. Copayments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect copayments and deductibles from patients can be considered fraud. Please help us uphold the law by paying your co-payment at each visit.
   b. Non-covered services. Please be aware that some--and all--of the services you receive may be non-covered or not considered reasonable or necessary by your insurance plan. You must pay for these services in full during the visit.
4. Claims submission. As a courtesy to you, we will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not a party.
5. Nonpayment. If your account is over 60 days past due, you will receive a letter from us or our agents stating that you must pay your account in full. Partial payments will only be accepted if otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency, and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During those 30 days, your doctor can only treat you on an emergency basis.
6. Missed appointments or Late Cancellations. If you cancel less than 24 hours or fail to show up for your appointment, our policy is to charge a “missed appointment fee,” which must be paid before rescheduling. You will be charged as follows: Office Visit $50; Office Procedure $100. (additional charges may apply if medication was ordered and cannot be returned or stored). This will allow more availability for patients who desire to be seen. These charges will be your responsibility and billed directly to you.
   Please help us to serve you better by keeping your regularly scheduled appointment.
7. Returned Checks. All returned checks will be subject to an external collection service and a collection fee of $25. In addition, to cover the cost of returned checks, you will be charged an administrative fee of $25 (which includes the bank penalty charges incurred) and the cost of certified mailing in addition to your returned check amount.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

I have read the above. I fully understand and accept the terms and conditions set forth.

Financial Responsibility
All professional services rendered are charged to the patient and are due at the time of service unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments.

Assignment of Benefits
I hereby assign all medical and surgical benefits, including major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, privat  insurance, and any other health/medical plan, to issue payment check(s) directly to LibertyMed Health for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

Authorization to Release Information
I hereby authorize LibertyMed Health to:

1. Release any information necessary to insurance carriers regarding my illness and treatments;
2. Process insurance claims generated in the course of examination or treatment; and
3. Allow a photocopy of my signature to be used to process insurance claims for the period of a lifetime.

This order will remain in effect until revoked by me in writing.

I have requested medical services from LibertyMed Health on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original

OPEN PAYMENT DISCLOSURE (Effective 01/01/2023)

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov

I have read and agree to all statements, terms, and conditions above.

Patient Authorization & Acknowledgement of Receipt
Authorization for the disclosure of Protected Health Information (PHI) for Treatment, Payment, or Healthcare Operations (164.508 (a)).

I, the undersigned, understand that as part of my health care, LibertyMed Health Group originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for the future care of treatment. I understand that this information serves as:

• A basis for planning my care and treatment;
• A means of communication among the health professionals who may contribute to my health care;
• A source of information for applying my diagnosis and surgical information to my bill;
• A means by which a third-party payer can verify that services billed were actually provided;
• A tool for routine healthcare operations such as assessing the quality and reviewing the competence of health care professionals.

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

Patient Consent for Use & Disclosure of PHI
Consent to the use and disclosure of Protected Health Information (PHI) for Treatment, Payment, or Healthcare Operations (TPO) (164.506 (a))

I understand that:

• I have the right to review the provider’s Notice of Privacy Practices prior to signing this consent;
• The provider reserves the right to revise its Notice of Privacy Practices at any time and that prior to implementation will mail a copy of any revised notice to the address I have provided, if requested;
• I have the right to object to the use of my health information for directory purposes;
• I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or health care operations and that the provider has already taken action in reliance thereon.

By signing below, I hereby give my consent to use and disclose my protected health information (PHI) to carry out treatment, payment, and health care operations (TPO).

Complete below if not signed by the patient (please indicate relationship)

This authorization shall be effective immediately and remain in effect for one (1) year from the date signed. This informed consent is subject to revocation if any time by written notification only.

A copy of this authorization is as valid as the original. The undersigned has the right to receive a copy of this authorization.

I have been advised of my right to receive a copy of this authorization.

I hereby certify that the above information is true and correct to the best of my knowledge.

Re: Permission To Discuss & Release Health Information

By submitting this form, I hereby grant the above provider permission to discuss and release my medical/health information with any of the individuals listed above. All prior designations are hereby revoked.