Intake Form

ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS
AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE
AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIAR

 

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay The Center for Integrative and Functional Health and Wellness, as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. I hereby authorize payment of, and assign my right to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, treatments, and/or medications that have been or will be rendered or provided; as well as designating  and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under. I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your  records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with  same. I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contract, PPACA governed plan/insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policies. I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action (including in my name and on my behalf) to obtain and/or protect benefits and/or payments that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitles, including the use of legal action against the health plan, the insurer, or any administrator. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA and PPACA, and that Healthcare Provider can pursue all rights that I/we may have under state and/or federal law regarding my/our health plan. This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, tests, treatments, or medications that have been previously provided by Healthcare Provider. A photocopy or scan of this document is considered valid and enforceable as the original.

If the patient is of school age, 16+, it is ok to treat in case of a medical emergency in my absence. If yes, please sign:

If this visit is related to an Auto Accident, please fill out the following’ if not, disregard.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

• We do NOT accept Worker's Compensation or Motor Vehicle Insurance Claims.
• Please do not discuss or negotiate your co-pays or deductibles with your provider.
• Please ask to speak with our financial advisors who better understand the insurance requirements, the rules and regulations that we must comply with, and how we can best help you with your financial considerations.
• Patient Obligations:
  1. Co-pays must be paid at time of service.
  2. Patients are responsible for their deductibles, co-insurance, out-of-pocket expenses, and any other agreed to services not covered by their insurance.
• Collection Policy: Any unpaid balances over 90 days will be forwarded to a Collection Agency, unless other arrangements have been made with our financial counselor.

• I acknowledge full financial responsibility for services provided to me by The Center for Integrative and Functional Health and Wellness, LLC.
• I understand that I am responsible for prompt payment of any portion of the charges not covered by insurance, including copayments, co-insurance, out-of-pocket expenses, and deductibles.
• I understand co-payments are due at the time of service, as well as any prior balance I may owe. I understand that under provisions of HIPAA (Health Insurance Portability and Accountability Act), my insurance company and/or employer group plan administrator may be notified if I fail to fulfill my financial obligations for payment.
• I agree to all reasonable attorney fees and collection costs in the event I default on payment of my charges.
• I also give my consent for the release of billing information and for the direct payment of authorized insurance benefits paid on my behalf to The Center for Integrative and Functional Health and Wellness, LLC.
  

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment, directly or indirectly.
• Obtain payment from third-party payers/collectors.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

The Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information has been made available to me. I understand that this organization has the right to change its notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my confidential information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.
It is the policy for The Center for Integrative and Functional Health and Wellness, LLC, to inform patients of pertinent test results. We may also be asked to discuss your health information with other family members, or a close friend. Laws prevent us from leaving any messages regarding these results without your permission.

By signing below, I acknowledge the following:

• I have been provided with a copy of the Notice of Privacy Practices.
• I give The Center for Integrative and Functional Health and Wellness, LLC, the authority to access my medication history automatically from Pharmacy Benefit Managers (PBMs).
• I give consent to call me using automated phone calls or to send text messages on my cell phone.