* required field

Patient Log # (office use only):    ________________________________________

If yes, please list the condition(s) being treated and the physician's name:

Any family history of the following diseases?  Please specify which family member.

“I HEREBY AUTHORIZE DR. KEITH MOBILIA, HEALTH CARE PRACTITIONER, HOSPITAL, CLINIC, OR OTHER MEDICAL OR MEDICALLY RELATED FACILITY TO FURNISH ANY AND ALL RECORDS, MEDICAL HISTORY, SERVICES RENDERED TO TREATMENT GIVEN TO ME OR ANY DEPENDENT FOR PURPOSES OF REVIEW, INVESTIGATION, OR EVALUATION OF ANY CLAIM SUBMITTED TO THE INSURANCE CARRIER(S).

I ALSO AUTHORIZE THE INSURANCE CARRIER TO DISCLOSE TO A HOSPITAL OR HEALTHCARE SERVICE PLAN, SELF-INSURER, OR AN INSURER, ANY MEDICAL INFORMATION OBTAINED IF SUCH DISCLOSURE IS NECESSARY TO ALLOW THE PROCESSING OF ANY CLAIM.

IF MY COVERAGE IS UNDER A GROUP CONTRACT HELD BY AN EMPLOYER, AN ASSOCIATION, TRUST FUND, UNION, OR SIMILAR ENTITY, THIS AUTHORIZATION ALSO PERMITS DISCLOSURE TO THEM FOR PURPOSES OF UTILIZATION REVIEW OR AUDIT.

THE AUTHORIZATION SHALL BECOME EFFECTIVE IMMEDIATELY UPON EXECUTION AND SHALL REMAIN IN EFFECT FOR THE DURATION OF ANY CLAIMS OR TERMS OF COVERAGE WITH THE INSURANCE CARRIER, INCLUDING A REASONABLE TIME THEREAFTER, UNTIL ITS FINAL CONSUMMATION.  THIS AUTHORIZATION SHALL BE BINDING UPON ME AND MY DEPENDENTS AND HEIRS, EXECUTORS AND ADMINISTRATORS.”

MEDICARE PART B 

I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE BENEFITS BE MADE EITHER TO ME OR ON MY BEHALF TO THIS OFFICE FOR ANY SERVICES FURNISHED BY THAT PHYSICIAN TO ME. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.

 

 

The Practice:

(a)   Is required by federal law to maintain the privacy of your PHI and to provide you with the privacy notice detailing the practice’s legal duties and privacy practices with respect to your PHI.

(b)  Under the privacy Rule, may be required by state law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law.

(c)   Is required to abide by the terms of this Privacy Notice.

(d)  Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all your PHI that it maintains.

(e)   Will distribute any revised Privacy Notice to you prior to implementation.

(f)    Will not retaliate against you for filing a complaint.

EFFECTIVE DATE

This Notice is in effect as of 4/15/2003

PATIENT ACKNOWLEDGEMENT

By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.

We are pleased to assist you with your medical insurance (if any). Please be aware that any insurance quotes are estimates only.

Pre-certification does not guarantee payment.  All coverage is determined at the time your claim is received by the insurance company.  Coverage may differ if your deductible has not been met, your annual maximum has been met, or your coverage table is lower than average.

Co-pays:

I understand that I am responsible for paying all co-payments at the time of service, prior to leaving.

Deductible:

If my insurance determines that I have not met my deductible, I understand that I will be fully responsible for payment, due and payable no later than 30 days after I am notified by my insurance and/or provider.

I acknowledge that I assume full financial responsibility for services rendered to me if my insurance carrier denies or fails to cover my claim for those services.  I understand the terms of this form and accept financial responsibility with or without the use of insurance coverage.