Healthcare Policy

HEALTHCARE POLICY

This Healthcare Policy sets forth the terms under which medical services are provided, the responsibilities of the patient or responsible party, and the facility's policies regarding treatment, privacy, billing, and records. By signing below the patient or authorized representative acknowledges understanding and acceptance of the provisions contained herein.

Patient Information

Male Female Other

Insurance Information

Medical History

Policy Acknowledgments and Consents

Consent to Treatment: I voluntarily consent to examination, diagnostic testing, and medical or surgical treatment rendered by authorized providers. I understand that no guarantees have been made as to the results of care.

I acknowledge and consent to treatment as described above.

Financial Responsibility and Assignment of Benefits: I understand that I am financially responsible for charges not covered or paid by my insurance, including co-payments, deductibles, and non-covered services. I hereby assign and authorize payment of insurance benefits directly to the provider and authorize release of medical information necessary to process claims.

I accept financial responsibility and assign insurance benefits.

Billing and Collections: If my account is referred for collection, I agree to reimburse reasonable collection costs, including attorney fees where permitted by law. I understand interest may be charged on outstanding balances as permitted by applicable law.

I understand the billing and collections policy.

Privacy and Use of Protected Health Information: I acknowledge receipt of the facility's Notice of Privacy Practices and understand how my protected health information (PHI) may be used and disclosed for treatment, payment, and healthcare operations in accordance with law. I authorize the use and disclosure of my PHI as necessary for treatment, payment, and healthcare operations.

I acknowledge receipt of the Notice of Privacy Practices.

Authorization for Release of Medical Records: I authorize the release of my medical information to the following persons or entities for purposes of treatment, payment, or health care operations. This authorization includes medical, billing, and insurance information but excludes psychotherapy notes unless specifically indicated.

Right to Revoke: I understand I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it. To revoke, I must submit a written request to the facility's privacy officer or designated office.

Authorization Expiration: Unless earlier revoked, this authorization will expire on . If no date is provided, the authorization will remain valid for the period necessary to complete the purpose stated herein, but no longer than applicable law permits.

Additional Notices

Advance Directives: If you have an advance directive, living will, or durable power of attorney for healthcare, you are encouraged to provide a copy to your medical record so that your care preferences are honored.

Grievance Rights: You have the right to file a complaint or grievance regarding the care provided or privacy practices. Complaints will be documented and investigated in accordance with facility policy and applicable law.

Vaccination and Infection Control Policies: The facility maintains infection control protocols. You agree to comply with screening and infection control measures as required for safe care of all patients and staff.

Patient Certification

I certify that the information provided on this form is true and accurate to the best of my knowledge. I have read and understand the Healthcare Policy provisions above. By signing, I accept responsibility for payment of services, consent to treatment as indicated, and authorize release of information as stated.

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