Acknowledgement of Receipt & Acceptance of Privacy Practices, Informed Consent & Financial Policies

ACKNOWLEDGEMENT OF RECEIPT AND ACCEPTANCE OF:
Notice of Privacy Practices | Informed Consent
Practice Financial Policies

Compliance Manager: Kandace Coe

I hereby acknowledge that I was given the opportunity to review this medical practice’s Notice Of Privacy Practices (HIPAA), and that I have the right to ask for a paper copy of the Notice to take with me. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I may request a copy of any amended Notice of Privacy Practices at each appointment. Due to HIPAA laws, we are unable to share your medical information with anyone unless you authorize to do so.

I authorize the person(s) listed below to discuss my medical information:

Person 1 Full Name

First NameLast Name

Person 1 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Person 1 Relationship To Patient

Person 2 Full Name

First NameLast Name

Person 2 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Person 2 Relationship To Patient

I authorize Advanced Specialty Care staff to leave medical information, including test results, on the following voicemail/answering machines:

Release of my medical records to my personal electronic portal authorization: I understand that this health information may include HIV-related information and/or information relating to diagnosis or treatment of psychiatric disabilities and/or substance abuse and that by signing this form, I am authorizing such information to be disclosed. This authorization is effective indefinitely unless revoked in writing.

Please note that ASC employees may discuss payment issues with family members or other personal representatives, including the subscriber of my insurance plan, unless I request special privacy protections. My signature on this form authorizes such financial discussion.

Please initial each statement on the line provided:

Under certain circumstances, this office may need to request lab reports, radiology reports, other diagnostic test results, and/or medication history from outside facilities in order to provide treatment. At times these facilities may require an authorization to release such records. My signature authorizes the release of these records.

Type your initials

I understand that audio and or video recording staff of ASC (including providers) without explicit permission to do so, may result in my being discharged from the practice along with any applicable legal consequences.

Type your initials

I understand that no procedure provided by this facility is completely without risk and I authorize the care and treatment provided to me under the general or specific directions of my physician or my physician assistant.

Type your initials

I understand that I will be charged a $25-$125 NO-SHOW fee if I do not show up at my scheduled appointment. In order to avoid the NO-SHOW fee an appointment needs to be cancelled 24 hours prior.

Type your initials

I understand any office procedures/tests done today may fall under a different insurance benefits classification, therefore may require additional out of pocket cost beyond the office visit fee.

Type your initials

If this office does not have a contract with my insurance company, payment must be made at the time of visit unless prior arrangements have been made with the office manager. For patients with coverage that we participate with we will file your insurance claims to your primary carrier for all services and procedures we provide. It is your responsibility to secure all referrals and authorizations required by your health plan and to be aware of its coverage and benefits. All charges are your responsibility from the date the services are rendered. I understand that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered. If payment is not received in a timely manner, my account will be turned over to a collection agency. I agree to notify the office of Advanced Specialty Care of any changes to my insurance coverage so that filing my claim is expedited. I understand that any unpaid balances 120 days or older will incur $15 per month late fee.

I'm submitting this form for...

Parent/Guardian Signature

Patient Signature

Parent/Guardian Name

First NameLast Name

Relationship To Patient

Patient Name

First NameLast Name

Patient Date of Birth

Date

Today's Date

Date

Advanced Specialty Care, P.C.