Consent for Treatment, Payment, and Health Care Operations
Please carefully review the following policies, initial each, then sign and date below:
CONSENT FOR TREATMENT: I hereby authorize the physicians, nurses, and other healthcare providers of Women's Health Physicians and Surgeons to provide such medical assessment and treatment, including drugs, medications, operations, imaging, and other studies, as they deem appropriate.
I accept
ASSIGNMENT OF BENEFITS: I hereby assign to Women's Health Physicians and Surgeons, or its duly authorized agents and/or assigns, all rights, benefits and interest in all proceeds from all Third Party Payors. I authorize payment directly to Women's Health Physicians and Surgeons of benefits otherwise payable to me for services rendered and further authorize Women's Health Physicians and Surgeons to take all necessary actions to ensure such benefits are paid directly to Women's Health Physicians and Surgeons. I agree to provide and sign any other documents that may be reasonably necessary to accomplish any of the above purposes. I understand that any amount paid to Women's Health Physicians and Surgeons in excess of regular charges will be refunded as appropriate.
I accept
FINANCIAL RESPONSIBILITY: I acknowledge that I am legally responsible to Women's Health Physicians and Surgeons for, and I agree to pay to Women's Health Physicians and Surgeons all charges that are not paid in full by a Third Party Payor including, but not limited to, co-payments, deductibles, coinsurance, and non-covered charges. Charges remaining on this account are payable upon demand. I hereby waive all claims for exemption, including without limitation exemption from levy or execution, under the laws of the State of Alabama, and if my account is transferred to a collector or an attorney for collection or suit, I will pay all reasonable costs of collection fees, including reasonable attorney fees.
I accept
CELL PHONE/EMAIL CONSENT: I agree that Women's Health Physicians and Surgeons may contact me for appointment reminders or to notify me of a balance due by telephone, text, or email at any telephone number or email address associated with my account. I understand that Women's Health Physicians and Surgeons are not responsible for any fees incurred to me by my cellular service provider.
I accept
CANCELLATION/ NO SHOW POLICY: I understand that a 24 hour notice must be given if I am unable to make my scheduled appointment. I understand that if I do not keep my appointment and fail to cancel or reschedule it within the 24 hour notice, this is considered a "no-show" and I will be personally responsible for a $25 no-show fee. I understand that if 3 no-shows have occurred, I will be dismissed from the practice.
I accept
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