Healthcare Medical Release and Fee Contract

HEALTHCARE MEDICAL RELEASE AND FEE CONTRACT

Patient Information

Date of Birth:    Gender:    Phone:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Subscriber Date of Birth:    Insurance Billing Phone:

Medical History

Description of Services, Fees and Payment Terms

Description of proposed service(s) or procedure(s):

Estimated Fee (total): $    Deposit Required: $    Payment Due:

Cancellation / No-Show Fee: $    Late Payment Interest:

Authorization, Assignment and Release of Records

Assignment of Insurance Benefits: I hereby assign to the provider all rights to payment for medical benefits and authorize insurance benefits to be paid directly to the provider. I certify that the information provided about insurance is correct and that I am financially responsible for charges not covered by insurance, including deductible, copayment, coinsurance and any amount deemed non-covered.

Authorization to Release Medical Information: I authorize the provider to release medical records, billing information and other protected health information to my insurance company, other treating providers, or any third party as necessary for treatment, payment and healthcare operations. This authorization includes disclosure of sensitive information where relevant, including but not limited to mental health treatment, substance use treatment, HIV/AIDS-related information and genetic testing, unless I have specifically noted restrictions below.

Recipient of Records (if not insurance):

Purpose of Release:

Authorization Expiration Date:

Consent to Treatment

I consent to the examination and treatment by the provider and clinical staff for the procedure(s) and services described above. The provider has explained the nature of the procedure, anticipated benefits, reasonable alternative treatments and materials risks, and potential complications. I understand that no guarantees have been made regarding the results of the procedure.

I understand that I may refuse or withdraw consent at any time prior to treatment, and that withdrawing consent may result in postponement or cancellation of services and potential financial consequences as set forth above.

Procedure/Service Date (if scheduled):

HIPAA Acknowledgment and Privacy

I acknowledge that I have been provided an opportunity to review the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I can obtain access to this information. I understand my rights, including the right to request restrictions and the right to revoke authorizations in writing, except where action has already been taken in reliance on this authorization.

  I acknowledge receipt of the Notice of Privacy Practices and understand my rights regarding protected health information.

Financial Responsibility and Collections

I agree to be financially responsible for all charges incurred for services rendered by the provider that are not paid by insurance. If my account is referred to a collection agency or attorney for collection, I will be responsible for reasonable collection and attorney fees, court costs and any applicable interest.

Responsible Party (if other than patient):

Acknowledgments and Miscellaneous

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I authorize the provider to obtain verification of my insurance coverage and to submit claims on my behalf. I understand that my signature confirms that I have read, understand and accept the terms of this Medical Release and Fee Contract.

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