New Patient Packet

1. NOTICE OF PRIVACY POLICIES: I have been offered a copy of the MON Notice of Privacy Policies detailing how my protected health information (PHI) may be used and disclosed as permitted under federal and state law. I understand that MON is permitted to disclose my PHI without my authorization to facilitate treatment, payment and health care operations. This notice is always available on the MON website (www.midorthoneuro.com) and at each office location upon request.

2. FINANCIAL POLICY: I have been offered a copy of the MON Financial Policy and acknowledge its requirements. This notice is always available on the MON website (www.midorthoneuro.com) and at each office location upon request.

3. ePrescribe: I understand that MON utilizes electronic health record software which incorporates ePrescribing technology. I understand that MON may access and use my prescription history through ePrescribing software to facilitate appropriate treatment.

4. PAPERLESS BILLING: MON delivers paperless billing statements via our patient portal. I understand that I am automatically enrolled to receive paperless billing statements via the email address provided at registration. Changes to statement preferences may be made via the patient portal at any time.

5. PATIENT PORTAL: The patient portal is the most efficient tool to securely request appointments and communicate with our staff members, allowing you to bypass our phone system completely. Registering by smartphone is fast and easy. Ask the front desk staff to send a text with the registration link. Use the link and temporary password to login. You may also follow the Patient Portal link on our website (www.midorthoneuro.com) and click “Sign Up Today.” You will need to enter your name, date of birth and email address as they appear in your MidOrthoNeuro account.

I acknowledge understanding of the items described on this Authorizations & Acknowledgements form.

Authorization for Release of Information:

• I understand that I have the right to revoke this authorization, in writing, at any time.
• I understand that a revocation is 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 insurance 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 upon signing 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.