Consent Form

You must be eligible with your insurance carrier or medical group at the time you see Dr. Shaban or have a procedure. AN AUTHORIZATION FROM A MEDICAL GROUP IS NOT A GUARANTEE FOR PAYMENT. If you are not eligible at the time services were rendered, you understand that you will be held responsible for all charges.

I understand that I will be responsible for a $50.00 missed appointment fee every time I fail to keep a scheduled appointment or I fail to cancel an appointment without a 24 hour notice. For a procedure, the fee is $100 if I no show, cancel, or reschedule after the appointment has been confirmed.

I hereby authorize Dr. Shaban and his associates to release any information acquired in the course of medical examination or treatment for insurance claim filing. A photocopy of this authorization shall be considered as effective and valid as the original.

I hereby authorize payment directly to Dr. Shaban or his associates for the amount due in my pending claim for physician’s services rendered to my child. A photocopy of this authorization shall be considered as effective and valid as the original.

I hereby authorize Dr. Shaban and his associates to obtain any necessary medical records from my child’s primary care physician, hospital, or laboratory pertaining to the care of my child. I further authorize this office to release medical records and results to my child's primary care physician. A photocopy of this authorization shall be considered as effective and valid as the original.

We want you to know that our office makes every effort to ensure patients are referred to the appropriate laboratory or hospital, in accordance with their insurance company’s requirements. However, since Dr. Shaban works with numerous medical groups and PPO insurance plans, there is a possibility that an error may occur.

Please be advised that it is your responsibility to know which laboratory or hospital your insurance company requires you to use for lab work or diagnostic studies. If you are unsure, we strongly encourage you to contact your insurance provider to confirm this information. Doing so will help prevent you from being held financially responsible for any charges resulting from the use of an out-of-network facility.

By signing below, I acknowledge and understand that I will be financially responsible for any fees incurred due to services provided to my child at a non-contracted laboratory or hospital.

The purpose of this form is to comply with the Federal Government mandate to protect patient privacy.

With my consent, the office Dr. Mohamed A. Shaban, Pediatric Gastroenterologist, may use and disclose protected health information (PHI) about me or my child to carry out treatment, payment, and healthcare operations (TPO). Please refer to the Notice of Privacy Practices available to you upon request, for a more complete description of such uses and disclosures. I have a right to review the Notice of Privacy Practices prior to signing this consent. Our office reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Dr. Mohamed A. Shaban, at 460 W. Sierra Madre Blvd. Sierra Madre, Ca. 91024.

With my consent. Dr. Shaban and / or his staff may call my home or any other number provided by me and leave a message on a voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care, including laboratory results among others.

With my consent. Dr. Shaban and / or his staff may mail to my home or other designated location, any items that assist the practice in carrying out TPO, such as appointment reminder cards, correspondence, and billing statements.

Communication

1.1 agree to receive health care services via telehealth. I understand that: A. I have the right to access Medi-Cal covered services through an in person, face-to-face visit or through telehealth. B. The use of telehealth is voluntary, and I may withdraw my consent to, or stop receiving services through telehealth at any time without affecting my ability to access covered services in the future. C. Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted. D. There may be limitations or risks related to receiving services through telehealth as compared to an in-person visit.

2.1 have read this document carefully, understand the potential limitations and risks of receiving services via telehealth, and have had my questions answered to my satisfaction

3. Although we do our best when checking eligibility to ensure patients' telehealth
services are covered by their insurances, please be understanding that this information in some cases is not as accurate as we like due to many different factors. If this service is not covered by insurance it will be the patient's responsibility to cover the telehealth fee.

So that you and your physician may take advantage of e-prescribing, we need you to provide information on the pharmacy that you choose to use to fill you or your child’s prescriptions. Feel free to speak with your physician if you have additional questions. Please keep us updated if your preferred pharmacy changes in the future.

Para que usted y el doctor aprovechen el servicio de enviar recetas electrdnicamente, necesitamos que nos provea con la informacidn que usted prefiera para las recetas suyas o de  su hijo/a. Sientase con confianza de hablar con su doctor si tiene alguna pregunta o duda.