1. ASSIGNMENT OF INSURANCE BENEFITS/PROMISE TO PAY:
I hereby assign and authorize payment directly to the Physician Clinical 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 Physician Clinic, outpatient visit or series of outpatient visits is paid in full upon discharge or upon completion of the outpatient series. If eligible for Medicate, 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 I further agree that this assignment will not be withdrawn or voided at any time until the account is paid in full.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 tor any charges not covered by my insurance company.
I understand that I am obligated to pay the account of the Physician Clinic in accordance with the regular rates and terms of the Physician Clinic, to make payment when due and the account becomes delinquent or is turned over to a collection agency or an attorney for collection, 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 Physician Clinic visit may be applied directly to any delinquent account for which or I my guarantor is legally responsible at the time of the overpayment. I consent for the Physician Clinic to appeal on my behalf any denial for reimbursement coverage, or payment for services or care provided me.
2. PATIENT CONSENT FOR E-PRESCRIBING (ELECTRONIC PRESCRIBING):
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 be able to see information about medications am already taking, including those prescribed by other providers, give my consent to my providers to see this protected health Information.
I have been provided the Electronic Prescribing Notice included the Notice of Privacy Practices.
3. NOTICE OF PRIVACY PRACTICES:
Required pursuant to Health Insurance Portability and Accountability Act of 1996(HIPAA), I acknowledge that I have received a copy of the Physician Clinic's Notice of Privacy Practices. I hereby consent to the use and disclosure of my protected health Information as described in Notice of Privacy Practices. This will include all of my protected health information generated during hospitalization and outpatient treatment at the Physician Clinic, including but not limited to treatment for mental health, drug and alcohol abuse, communicable diseases such as HIV/AIDS, developmental disabilities, genetic testing, and other types of treatment received.
4. GENERAL CONSENT FOR TESTS, TREATMENT, AND SERVICES:
I have been informed of the treatment considered necessary for me and that the treatments/ procedures will be directed by a physician or independent Advanced Practitioner, in accordance with state laws, scope of practice, and licensure medical staff.
I hereby consent to engaging in virtual health/telemedicine services, where available, as part of my treatment. I understand that "virtual health" or telemedicine services includes the practice of health care delivery, diagnosis, consultation, treatment, transfers of medical data, and education using interactive audio, video, or data communications.
5. ADVANCE DIRECTIVE ACKNOWLEDGEMENT:
Federal law requires that patients be provided information about their rights to make advance health care decisions, including Living Will, Durable Medical Power of Attorney or designation of surrogate decision made of healthcare decisions. If you have already completed any of these documents, please inform your physician and the Physician Clinic.