Patient Authorization and Consent
Rooming Policy: To provide high quality, comprehensive and confidential care, it is Family Tree’s policy to see each patient alone for a portion of their visit. Patients are roomed by themselves at the beginning of the visit to speak with the medical assistant and provider. Once this process is complete, patients can request to have a companion escored to the exam room to join them.
Insurance or State Programs: - I hereby authorize Family Tree Inc. to release to my insurance or program any information, including diagnosis and records of treatment concerning my medical care. I request payment of services to be made to Family Tree. I understand that if I am covered by my parent’s policy and want Family Tree to bill the insurance for my visit, my parents may receive a copy of the charges from their insurance company. Note: Insurance companies are billed for the full cost of the visit. If your insurance company doesn’t cover any portion of your visit, you will be responsible for the unpaid balance. Additionally, if you have privacy concerns, please discuss this with our staff to determine options for payment.
Quest Diagnostics: Family Tree Clinic sends labs to Quest Diagnostics. Patients may receive a separate bill from Quest.
Patient’s Right to Privacy: By signing below, I acknowledge that I have reviewed a copy of the Privacy Notice. Public copies of the Privacy Notice and Client’s Rights and Responsibilities brochure are posted in the reception area.
Consent for Treatment: By signing below, I consent to having my healthcare provider examine and treat me. I understand that this could include education, lab tests, and / or diagnostic procedures. I understand that my provider will explain the purpose of procedures and treatments and that I have the right to refuse the recommended treatment.
Income Verification: By signing below, I certify that all information regarding my income is complete and correct.
Authorization for Payment: By signing below, I give permission for my insurance carrier to pay Family Tree Clinic directly. I understand that I am responsible for payment of all co-insurance and deductibles, as well as any treatment, care and services not covered by my insurance.