Self-Pay Financial Responsibiltiy Agreement

I understand I am responsible for full payment of the County Health Deparment's scheduled fees at the time of services unless I qualify for special discounted fees. Certain programs offer assistance or a payment plan for said services. Discounted fees are based on my personal and/or household's income (with proof of income) and number of dependents, which I have provided truthfully and accurately to the County Health Department staff. I also certify that I have notified the County Health Department staff if any income or insurance information has changed since my last visit. 

Insurance Financial Responsibility

I understand the County Health Department will submit my claim to my insurance if they are a participating provider for services, however, I understand that I am ultimately responsible for all payment obligations arising out of my treatment or care including, deductibles, co-payments, co-insurance amounts or any other patient responsibility indicated by my insurance. I understand that any amount deemed as the patient responsibility by my insurance company will be my financial responsibility and billed to me as such. Payment of unpaid services will be expected within 30 days of billed date, unless a payment plan has been put in place for said services. 

If you are not familiar with your insurance coverage, NCHD/County Health Department recommends you contact your insurance carrier or plan provider directly. Your insurance company makes the final determination of your eligibility and benefits. If the patient/guardian disagrees with the determination made by their insurance carrier, the patient/guardian must contact the insurance company directly to appeal the decision. 

General Consent for Treatment

I hereby authorize the County Health Dpartment to render the appropriate services and presumptive treatment at my request. I understand that to render care, the staff may need to examine me, conduct tests or diagnositc procedures, administer medicines or treatments. I understand that I will have an opportunity to ask my healthcare provider questions regarding such care and read any informational materials given to me as deemed appropriate. I acknowledge that all of the information I have provided to the County Health Department staff is true and accurate to the best of my knowledge.

Laboratory Services

I understand that some laboratory services are completed onsite and some are completed by an independent lab company at their facility. Charges for labs will be due at the time of your visit unless we are billing your insurance company. I also understand if I have insurance the County Health Department will provide my insurance information to the independent lab company for their billing purposes. 

North Central Health District Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have reviewed and understand the Notice of Privacy Practices for the North Central Health District. The Notice sets forth the ways in which my personal health information may be used or disclosed by the North Central Health District or the County Health Department and outlines my rights with respect to such information.