BECAUSE THERE ARE IMMEDIATE EXPENSES TO PROVIDE A SERVICE TO OUR PATIENTS, WE EXPECT YOU TO CONTRIBUTE YOUR PORTION WHEN APPLICABLE. THE FOLLOWING FORMS OF PAYMENT ARE REQUIRED.

INSURANCE: We will bill your insurance as a courtesy.

I have read the above office payment policy and as a patient, or legal guardian of a minor or impaired patient, I understand that regardless of any insurance coverage I may have, I am responsible for payment of my account. I understand there is no interest or finance charge on current accounts. However, I am also aware that delinquent accounts beyond 90 days are subject to other collection means at my own expense and no further appointments will be scheduled until my account is paid in full unless prior arrangements have been made. I understand I may request a payment plan if necessary to keep my account in good standings. 

I have read, understand, and agree to the above office payment policy in accordance with the terms and conditions set forth in the policy of this office. I also hereby attest that I have given payment information to the best of my knowledge for complete and timely payment. 

Family Tree Medical Clinic reserves the right to revise this agreement at any time with or without your consent. Last Revised: 12/31/2024

I, {patientFull}  authorize Sarah L. Agsten, D.O. LLC, DBA Family Tree Medical Clinic to use and disclose my medical information described below to the following person(s):

The health information to be used and disclosed includes the information specifically authorized below as well as all other information in my health records relevant to scheduling/discussing appointments or referrals; disclosing lab and/or imaging results.

If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed if I place my initials in the applicable space next to the type of information. 

I have reviewed and I understand this Authorization. I also understand that the information used ordisclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer beprotected under federal law.

I understand that Family Tree Medical Clinic, Referred to below as ("This Practice") will use and disclose health information about me.

I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken works, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health related information.

I understand and agree that this practice may use and disclose my health information in order to: Make decisions about and plan for my care and treatment; Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment; Determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies and other who may be responsible to pay for some or all of my health care; and Perform various office, administrative, and business functions that support my physician's efforts to provide me with, arrange, and be reimbursed for quality, cost-effected health care.

I also understand that I have the right to receive and review a written description of how this practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff, and other office personnel of This Practice, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice's Notice of Privacy Practices in effect will be posted in the waiting/reception area.

I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.

We participate in local and national health information exchanges that permits health care providers to electronically exchange health information. Your health information may be shared with other providers and organizations when necessary and as appropriate for our and their treatment, payment, and health care operations purposes.

You may access the full Notice of Privacy Practices here:Click Here

By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices.

Please note, you are consenting to the release of all records, including lab reports, imaging reports, diagnostic reports, and colonoscopy and pathology reports. 

I have reviewed and I understand this authorization. I also understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected under federal law. Unless revoked earlier, this authorization shall remain in effect until my death.