HEARTLAND HEALTH CENTER CONSENT TO TREAT
I authorize the professional staff at Heartland Health Center (HHC) to furnish any and all diagnostic and therapeutic services and supplies that I may require, from time to time, for the treatment of my medical condition(s) then existing, including, but not limited to, medical history, physical examination, assessment of health status, laboratory- testing, emergency procedures, suturing, prescription medications, and immunizations. I give permission to HHC to check my prescription-fill history through PDMP. I acknowledge that I may at any time request information from the professional staff at the HHC regarding the diagnostic and therapeutic services or supplies provided to me. I acknowledge that no guarantees have been made to me as a result of diagnosis, treatment, test or examinations at HHC.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY and PATIENT RIGHTS & RESPONSIBILITIES
I have been offered a copy of the Notice of Privacy Practices of HHC containing a more complete description of the uses and disclosures of my health information. I understand that HHC has the right to change the Notice of Privacy Practices from time to time and that I may contact HHC at any time to obtain a current copy of the Notice of Privacy Practices. I have also been offered a copy of the Patient Rights & Responsibilities.
RELEASE OF INFORMATION
When we examine, diagnose, treat, or refer you, we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions.
I give HHC my consent to use or disclose my PHI to carry out my treatment and to obtain payment from insured companies, as well as for health care operations, like quality reviews. I understand that I have the right to request a restriction of how my PHI is used. You will have to tell us what you want in writing. However, I also understand that HHC is not required to agree to the request. If HHC agrees to your requested restriction, we must follow the restriction(s). If you have paid out of pocket in full for certain services and you do not want information about those services shared with a health plan, we will not disclose information about those services unless the disclosure is required by law. I also understand that I may revoke my consent for HHC to use or disclose my PHI at any time by making a request in writing except for information already used or disclosed.
MEDICARE/MEDICAID AUTHORIZATION
I authorize HHC to release to Medicare and/or Medicaid, to the Social Security Administration and/or its intermediaries or carriers, and to any peer review organization, any information needed for this or a related Medicare and/or Medicaid Claims. I request the payment of authorized benefits be made on my behalf to HHC for medical care and treatment.
ASSIGNMENT OF BENEFITS AND GUARANTEE OF PAYMENT
I authorize and assign payment directly to HHC of any major medical, basic health insurance or Medigap benefits payable to me but not to exceed HHC's regular charges for my care. I understand that I am responsible for the charges not covered by this assignment, and further agree to guarantee full payment of all expenses not covered by Third Party Payers. For good and valuable consideration of services to be rendered to the patient identified on this sheet, I hereby guarantee full payment of all expenses. I agree to pay for any and all charges not paid pursuant to this assignment.
COMMUNICATIONS CONSENT
By providing my cell, landline, or any other number(s), I hereby consent to receiving communications from HHC and its staff at any numbers I provide or that are later acquired for me. HHC and its staff may use this information to contact me by live agent, voice mail, text message, using an auto dialer or other computer assisted technology, pre-recorded message(s), or by any other form of electronic communication for any purpose including, but not limited to, appointment and follow-up health care reminders. I understand that depending on my phone plan, I could be charged for these calls or text messages. I agree to provide new number(s) if my number(s) change. Providing these numbers is not a condition of receiving services from HHC