CONSENT: The information on this form is true to the best of my knowledge. I voluntarily consent to out-patient care at Mid-Delta Health Systems which may include diagnostic procedures, examinations, and/or treatment by MDHS’s providers and/or other staff of the clinic.
RELEASE OF INFORMATION: I authorize Mid-Delta Health Systems to release medical information to third-party insurance carriers for the purpose of filing claims, and to release or obtain medical information to/from providers of medical care and the Health Department for the purpose of continuity of care. I authorize payment of medical benefits by my insurance to Mid-Delta Health Systems. I consent for those listed on this form to receive any and all information regarding my healthcare, personal observations and concerns, treatment plans, and prognosis.
PRESCRIPTION HISTORY CONSENT: This facility participates in the Prescription Drug Monitoring Program. Clinicians in this office will not prescribe narcotics, benzodiazepines, or controlled medications for chronic use. I authorize Mid-Delta Health Systems to obtain and review my prescription history from pharmacies, other providers, and other third-party entities such as insurance companies.
TRAINING FACILITY: I understand that occasionally health care students may be working with my provider. I give consent to have a health care student observe or participate in my care while under the supervision of my provider. I understand that these health care students are under the same confidentiality policies as my provider. I acknowledge that I have the option of declining consent.
PATIENT BILL OF RIGHTS/PRIVACY NOTICE: If I want one, I have been given a copy of Mid-Delta Health Systems Patient’s Rights and Privacy Notice.
EFFECTIVE PERIOD: I understand this consent/authorization will be valid and remain in effect as long as I attend the clinic or until I revoke this authorization in writing.Medicaid/ARKids: I understand that if I have Medicaid, this facility must be designated as my Primary Care Physician. If Mid-Delta Health Systems is not my PCP, I acknowledge that I must obtain a referral for services from my PCP or the full amount of services will be due at the time of visit. I understand I am responsible for ANY services not covered by Medicaid or ARKids.Medicare: I understand that I will be responsible for any service or lab not covered by my Medicare or Medicare replacement plan.
Sliding Fee Scale/Self-Pay: I understand that Mid-Delta Health Systems offers reduced fees on a sliding fee scale based on household income. If I wish to apply for the sliding fee scale, I will fill out the provided form and return my proof of income within 48 hours of visit. If I qualify for reduced fees, I understand that I will be asked to pay an initial fee of $15 for medical or $30 for dental at check-in. Any remaining charges will be collected at check out. If I do not have insurance and do not qualify for the sliding fee scale, I will be asked to pay a set fee of $15 for medical or $30 for dental at check-in and additional charges at check-out.
IF YOU ARE UNABLE TO PAY ANY OF THE ABOVE FEES AT THE TIME OF YOUR VISIT YOU MAY BE RESCHEDULED.