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PATIENT CONSENT, ACKNOWLEDGMENT, AND AUTHORIZATION
VISIT CONSENT/RELEASE:
I understand that this wellness visit is designed to determine preventive health recommendations only, and is not an examination to detect and/or treat any health issues or diseases. I further understand, it is my responsibility, and at my own discretion, whether to follow-up on any health recommendations that were provided by HealthPoint Wellness LLC and I hereby release HealthPoint Wellness LLC, as well as their staff, from any, and all liability, which may arise from my failure to seek necessary healthcare, regular or otherwise.
INSURANCE AUTHORIZATION/ASSIGNMENT RELEASE:
I request that payment of authorized medical benefits be made to HealthPoint Wellness LLC for any services provided to me. This assignment of benefits includes Medicare, state medical assisted agency programs, commercial insurance, managed care plans, and any third party payer benefits that I may have. I authorize the use of this signature on all my insurance claim submissions.
I authorize any holder of medical and other information about me to release to Medicare and its agents, any insurance company, any third party payer, state medical assistance agency, or any other governmental or private payer responsible for paying such benefits, any information required to determine these benefits for related services.
I authorize a copy of this authorization to be used in place of the original.
FINANCIAL RESPONSIBILITY:
I am responsible for all the financial obligations of health services, and for the reimbursement and payment of claims from my insurance company. I understand that I am responsible for any amount not covered by insurance. I also understand that if a payment becomes more than 90 days past due, I will be responsible for the balance due on my account as well as any and all reasonable attorney fees and costs of collections in the event of default.
COMMUNICATION CONSENT:
I allow HealthPoint Wellness LLC to contact me in the future by phone, text, email, and/or mail. I understand that e-mail and/or text is not a confidential means of communication. I agree to waive any rights that I may have against HealthPoint Wellness LLC, any affiliated organization, or provider for any loss of information due to technical failures and/or unintended breach of confidentiality, due to unauthorized access to my information, as a result of my decision to communicate with HealthPoint Wellness, LLC in this manner.
RECEIPT OF NOTICE OF PRIVACY PRACTICES:
I have received the Notice of Privacy Practices from HealthPoint Wellness LLC.
CONCIERGE CONSENT & AUTHORIZATION:
I authorize HealthPoint Wellness and its providers to disclose necessary protected health information to affiliated institutions in order to provide health concierge/navigator services or accommodate other applicable healthcare orders. This includes, but is not limited to, demographics, visit notes, medical records, wellness guidelines, and health history. Additionally, by signing this form, I allow the Health and Wellness Concierge/Navigator or affiliated personnel to contact me in the future by phone, text, email, and/or mail regarding my wellness visit recommendations.
