Authorization to Release: I hereby authorize my insurance company benefits to be paid directly to St. Anthony Regional Hospital whose name appears on form. I am financially responsible for non-covered services. I authorize the clinic to release any information to process this claim.
Payment Policy: Co-payments are to be expected at the time services are received. We accept cash, checks, Visa, MasterCard, and Discover. All medical services provided are directly charged to the patient or responsible party. You are responsible for any balance deemed patient responsibility/non-payable/non-covered by your insurance company and will be billed accordingly.
Payment is expected in full upon receipt of statement or payment arrangements must be made with the Patient Finance Department at St. Anthony at 712-794-5507.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
By my signature below, I acknowledge that I have been provided a copy of St. Anthony Regional Hospital's Notice of Privacy Practices
NOTICE OF PATIENT RIGHTS/RESPONSIBILITIES
By my signature below, I acknowledge that I have been provided a copy of St. Anthony Regional Hospital's Patient Rights / Responsibilities
Release of Information to Family Members
I authorize the staff of St. Anthony Regional Hospital, Nursing Home and Clinics to release the information specificed below.
Inpatients: This authorization is valid throughout your hospital stay unless specified otherwise.
Nursing Home/Clinics: This authorization is valid for one year unless specified otherwise.