Patient Demographic Information

NOTICE OF PRIVACY PRACTICES:

Required pursuant to Health Insurance Portability and Accountability Act of 1996 (HIPPA), I acknowledge that I have received a copy of the Facility's Notice of Privacy Practices. I hereby consent to the use and disclosure of my protected health information as described in the Notice of Privacy Practices. This will include all of my protected health information generated during hospitalization and outpatient treatment at the Facility, including but not limited to treatment for mental health, drug and alcohol abuse, communicable diseases such as HIV/AIDS, developmental disablilites, genetic testing, and other types of treatment received.

GENERAL CONSENT FOR TESTS, TREATMENT, AND SERVICES:

I agree and understand that all physicians (including fellows, residents, physician assistants, nurse practitioners, and interns) involved in my care in any way are responsible and liable for their own acts and omissions, and the facility/practice is not responsible or liable for the acts or omissions of the aforementioned. Services may be performed by independent contractors who are not employed by the facility. I am aware that the practice of medicine is not an exact science and further understand that no guarantee has been or can be made to the results of the treatments, care or examinations in the Facility.

I will be informed of the treatment procedures considered necessary for me and that the treatments/procedures will be directed by a physician and may be performed by such physician and/or one or more additional physicians, fellows, residents, interns, and employees of the Facility.

I understand that one or more physicians, fellows, residents, and/or interns at the Facility may treat me or participate in my treatment. I understand that no guarantee or assurance has been made regarding (1) which physicians and/or fellows, residents, or interns will treat me or participate in my treatment and/or (2) the results that may be obtained from treatment.

I hereby authorize and consent to treatment by AllianceHealth Medical Group. I authorize my Protected Health Information (PHI) to be furnished to any licensed Physician, Medical Practitioner, Hospital, or other medically-related facility concerning my illnesses and treatments and to be used for the purpose of obtaining reimbursement for the provision of healthcare.

I hereby consent to provide my telephone number(s), including wireless telephone number(s), so that representatives from the Facility, its successors or assigns can contact me in any manner including but not limited to by manually placing a call, by using an automatic telephone dialing system or an artificial or prerecorded voice, by texting, or by emailing, regarding any manner, including but not limited to my medical treatment, prescriptions, insurance eligibility, insurance coverage, scheduling, billing or collection matters. This consent includes any updated or additional contact information that I may provide. I understand that I will be able to change my preference at any time.

I understand this designation applies only to this AllianceHealth Medical Group office (ie. I must request this designation at all other entities, including other Alliance Health entities, if I want them to adhere to my request).

If I choose to enroll in the patient portal, I agree to read and agree electronically to the Terms of Use and Privacy Policy documents on the Follow My Health website or app. This will acknowledge that I (a) have read and understood the Terms and Conditions of Use and agree to be legally bound by that Agreement; and (b) am at least 18 years old and/or have the legal authority to agree to the provisions I also understand the portal is not for use in emergency or urgent situations.

What is your preferred communication method? Please check one:

Thank you for choosing AllianceHealth Medical Group! We are committed to the success of your medical treatment and care. Our practice firmly believes that a good doctor/patient relationship is based upon understanding and open communications. Therefore your complete understanding of our financial policy as it relates to your financial obligations is an essential part of our relationship. Please read this document thoroughly, sign and date the bottom indicating you understand and agree to comply with these policies.

• Payment for all services provided by our practice is due in full at the time the services are rendered. Exclusion to this policy is those patients who are a member of an insurance company health care organization that your physician participates with.
• If you are a member of an insurance company health care organization that your physician participates with, we will file your visit with your insurance and your co-payment, deductible, and co-insurance is expected at the time you arrive for your appointment.
• If you are unable to pay your co-payment, deductible, or co-insurance at the time you arrive for your appointment, you may be asked to reschedule your appointment.
• Under no circumstances does AllianceHealth Medical Group extend Professional Courtesy discounts.
• If you are scheduled with an AllianceHealth physician that is not listed as your PCP, you will be asked to reschedule until such time your PCP can be verified has changed.
• Your insurance coverage is an agreement between you and your insurer. It is your responsibility to remit payment for charges not covered by your claim and ensure your carrier remits payment. If a problem occurs with your claim, you will be required to establish written financial arrangement with our practice until your insurance problem is resolved.
• AllianceHealth Medical Group ACCEPTS ASSIGNMENT ON MEDICARE. Medicare patients are responsible for their co-payments, deductibles, co-insurance and any items deemed Medically Unnecessary by Medicare.
• Lab services will be billed according your insurance plan. It is your responsibility to notify the physician if your insurance plan has a specific lab provider.
• If you receive x-ray services, you may receive a separate bill.
• We DO NOT file claims to Third Party Payors, (State Farm, Farmers, etc.) for Motor Vehicle Accidents. As a courtesy we will file the claim to your medical insurance. In the event the claim denies, you will be responsible for payment in full.
• Generally we do not treat Workers Compensation injuries. It is the patient's responsibility to notify the receptionist if your visit is related to an injury sustained on the job.
• Patients will receive a monthly statement itemizing claims submitted on their behalf, payment received, and appropriate patient balance due.
• It is the policy of Alliance Health Medical Group that any patient at the age of eighteen years or older will be financially responsible for all charges incurred. AllianceHealth Medical Group does not get involved with billing issues arising from divorce or separation. For any patient under the age of eighteen, the custodial parent will be responsible for all charges incurred.
• You will be billed in full for any services that your health plan deems to be a non-covered service or any balances due after we have received payment from your insurance carrier. All patient balances are payable in full (14) days after receipt of the statement.
• If you are unable to pay in full, you will be required to establish a reasonable written financial arrangement with our practice. There may be additional charges applied to your account if
• AllianceHealth Medical Group is asked to participate in a Deposition, phone consultation, or producing of medical records.
• AllianceHealth Medical Group accepts Cash, Personal Checks, Money Orders, Visa, MasterCard, American Express, Discover and ATM debit cards as payment for services rendered.
• A $20 Returned Check Fee will be assessed to the account for every check returned to Alliance Health Medical Group for insufficient funds.
• Refunds are processed on a monthly basis. Refunds will be given in the form of a check.
• AllianceHealth Medical Group reserves the right to turn any patient over to collections if it is deemed that the account has been in default of the payment obligations or compliance of this policy.
• In the event you are unable to make your scheduled appointment, please contact your physician (24) hours prior to the appointment. AllianceHealth Medical Group Physicians reserve the right to discharge any patient for (3) no shows.

I have been made aware and understand that the medical practices and offices may use an electronic prescription system which allows prescriptions and related information to be electronically sent between my providers and my pharmacy. I have been informed and understand that my providers using the electronic prescribing system will be able to see information about medications I am already taking, including those prescribed by other providers. I give my consent to my providers to see this protected health information. I have been provided the Electronic Prescribing Notice included in the Notice of Privacy Practices.

Assignment of Benefits/Promise to Pay:
I hereby assign and authorize payment directly to the Facility, and to any facility-based physician, all insurance benefits, sick benefits, injury benefits due because of liability of a third-party, or proceeds of all claims resulting from the liability of a third party, payable by any party, organization, et cetera, to or for the patient unless the account for this Facility, outpatient visit or series of outpatient visits is paid in full upon discharge or upon completion of the outpatient series. If eligible for Medicare, I request Medicare services and benefits. I further agree that this assignment will not be withdrawn or voided at any time until the account is paid in full. I understand that I am responsible for any changes not covered by my insurance company.

I understand that I am obligated to pay the account of the Facility in accordance with the regular rates and terms of the Facility. If I fail to make payment when due and the account becomes delinquent or is turned over to a collection agency or an attorney for collection, I agree to pay all collection agency fees, court costs and attorney's fees. I also agree that any patient or guarantor overpayments on the above Facility visit may be applied directly to any delinquent account for which I or my guarantor is legally responsible at the time of the collection of the overpayment. I consent for the Facility to appeal on my behalf any denial for reimbursement, coverage, or payment for services or care provided to me. Patient Initials

I consent to the photo/videotaping, including appropriate portions of the body, for medical and medical record documentation purposes, provided said photographs or videotapes are maintained and released in accordance with protected health information regulations.

Thank you for choosing AllianceHealth Medical Group. We understand you have a choice in healthcare and we appreciate you putting your trust in us. We will strive to ensure you are very satisfied with your care!

 

The undersigned verifies that he/she has read the foregoing, understands it, accepts its terms, has received a copy if one was requested, and is the patient or is duly authorized by the patient as their agent to execute the above.