APPOINTMENT REMINDERS AND HEALTH CARE INFORMATION AUTHORIZATIION

  Your Physician and members of Bellevue Total Health may need to use your name, address, phone number, and your clinical records to contact you with appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you.  If this contact is made by phone and you are not at home, a message will be left on your answering machine. By signing this form, you are giving us authorization to contact you with these reminders and information.

  You may restrict the individuals or organizations to which your health care information is released or you may revoke your authorization to us at any time; however, your revocation must be in writing and mailed to us at our office address.  We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization.  In addition, if you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.

  Information that we use or disclose based on the authorization you are giving us may be subject to re-disclosure by anyone who has access to the reminder or other information and may no longer be protected by the federal privacy rules.

  You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, or other health related information at any time.

  This notice is effective on the date of your first visit.  This authorization will expire seven years after the date on which you last received services from us. I authorize you to use or disclose my health information in the manner described.  I am also acknowledging that I have received a copy of this authorization.

CONSENT FOR USE OF DISCLOSURE OF HEALTH INFORMATION

OUR PRIVACY PLEDGE

We are very concerned with protecting your privacy.  While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information.

There are several circumstances in which we may have to use or disclose your health care information.

·         We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.

·         We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services.

·         We may need to use your health information within our practice for quality control or other operational purposes.

We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form. We reserve the right to change our privacy practices as described in that notice. If we make a change to our privacy practices, we will notify you in writing when you come in for treatment or by mail. Please feel free to call us at any time for a copy of our privacy notices.

Your right to limit uses or disclosures

You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions.  However, if we agree with your restrictions, the restriction is binding on us.

Your right to revoke your authorization

You may revoke your consent to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.

I have read your consent policy and agree to its terms.  I am also acknowledging that I have received a copy of this notice.

FINANCIAL POLICY

The following is a statement of our financial policy, which we require you to read and sign prior to any treatment in order to help keep healthcare costs down. There are numerous changes that have taken place in the health insurance industry. Procedures that were once covered in full are now partially covered or not covered at all. We eliminated costly billing fees by collecting payment for non-covered services, deductibles, and co-payments at the time of service. This savings is reflected in our fee schedule. Consequently, when you check out, we will be asking you how you plan on taking care of your bill. All patients’ must complete and sign our entrance forms and financial agreement before seeing our providers.

1.      I understand that I am responsible for all fees incurred by myself and/or my dependents. If I have insurance I also understand that I am responsible for all fees incurred by myself and/or my dependents regardless of what my insurance allows as usual and customary. I understand if my insurance denies my claims, I am still responsible for my deductible, co-pay and balance of the charges.

2.      If I have insurance I understand that I am solely responsible for knowledge of my insurance benefits, including but not limited to amount of deductible, co-pays, co-insurance, and any limitations. It is my responsibility to provide you with current/correct medical insurance information. Please understand that it is unlikely for us to know your exact individual benefits of your specific policy. We may provide you with an estimate of what your individual benefits are for your specific policy. We may provide you with an estimate of what your insurance coverage is based on what your insurance company told us but it is not a guarantee of benefits. Services not payable by insurance, co-payments, and deductibles are expected to be paid in full at time of services. Please be prepared to make a payment. If you make any payment that is later covered by your insurance, a refund will be issued to you. For your convenience we accept cash, check, debit cards and most credit cards.

3.      Accounts are due and payable monthly as work progresses, regardless of insurance coverage. If you do not have insurance, payment for all services is due in full on the date of service, unless prior financial payment arrangements have been made. If you have a balance on your portion, payment is due within 30 days of services. A 1% per month (12% per annum) late fee will be assessed on an unpaid balance remaining after 30 days.

4.      If you do not have insurance and are paying by cash/check for your medical and physical therapy services, in appreciation for payment of total charges in full on the day of service we offer a 5% courtesy. If payment is made in full with a debit or credit card we will offer no courtesy discount. Some exclusions may apply.

5.      I understand there will be a $45.00 charge for all missed appointments that are not cancelled at least 24 hours in advance. A $40.00 charge will be added for any nonsufficient funds checks that have been written.

6.      All X-rays taken in this office are the sole property of this facility.

Authorization for Treatment

I understand that if I am accepted as a patient by the providers of this office, I am authorizing them to proceed with any treatment that may be necessary.  Furthermore, any risks regarding my treatment will be explained to me upon request.  Thank you for your cooperation in this matter and we look forward to serving you and your family.  If you have any questions please do not hesitate to ask.

I have read and understand this financial policy.

LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS 

In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Bellevue Total Health, S.C. all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for service rendered from such doctor and clinic, I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee benefits

    I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses insured as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claims, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic’s expenses.

    This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.