Healthcare Policy Document

HEALTHCARE POLICY DOCUMENT

Identification

Facility Name:

Facility Address:

Patient Information

Insurance and Billing

By signing this document the patient assigns benefits and authorizes the facility to submit claims to the listed insurer(s) for services rendered. The patient is responsible for co-payments, deductibles and non-covered services as set forth in the facility's billing policy.

Medical History

Consent for Treatment and Policies

I, the undersigned patient or legal representative, authorize the facility and its licensed practitioners to provide evaluation, diagnostic procedures, medical and surgical treatment, and emergency care as deemed necessary in the professional judgment of the treating clinicians. I understand that no guarantees have been made to me as to the results of treatment.

I acknowledge that I have been informed of reasonably foreseeable risks, benefits and alternatives to proposed procedures or treatments. I acknowledge my right to ask questions and to have those questions answered to my satisfaction prior to treatment. I understand that I may revoke consent in writing at any time, except to the extent that action has already been taken in reliance on this consent.

I consent to routine and emergency medical care as described above.

Privacy, Confidentiality and HIPAA Acknowledgment

The facility maintains and protects health information in accordance with applicable privacy law. Protected health information may be used or disclosed for treatment, payment, and healthcare operations. This document serves as my acknowledgment that I have received and had the opportunity to review the facility's Notice of Privacy Practices describing how health information is used and disclosed.

I authorize the facility to disclose health information to the following persons and specify the scope of disclosures below.

I acknowledge receipt of the facility's Notice of Privacy Practices and understand my rights regarding access to and control of my protected health information.

Release of Medical Records

I authorize the release of my medical records as necessary for treatment, payment, continuity of care, public health reporting and as otherwise permitted by law. This authorization includes but is not limited to medical history, diagnoses, treatment notes, imaging, and billing records except as limited below.

This authorization will remain in effect until revoked in writing by the patient or legal representative. Revocation will not affect disclosures already made in reliance on this authorization. Certain disclosures may be required by law and cannot be revoked retroactively.

Infection Control & Workplace Safety

The facility follows established infection control practices. Patients agree to comply with infection control instructions, screening requirements and to report symptoms consistent with contagious illness. The facility may take appropriate measures, including isolation, to protect patients and staff.

Complaints, Grievances and Appeals

Patients have the right to file a complaint or grievance concerning services, billing, or privacy practices without fear of retaliation. Complaints may be submitted in writing to the facility's designated patient relations contact or made verbally and will be investigated in accordance with facility policy.

Legal Terms and Governing Law

This Healthcare Policy Document constitutes the administrative policy and informed consent between the patient and the facility. The patient acknowledges that this document does not create a contract for guaranteed results. Disputes arising from the interpretation or enforcement of this document shall be governed by applicable law of the state where the facility is located.

Patient Acknowledgment and Certification

By signing below, I certify that I have read or had read to me the policies and consents contained in this Healthcare Policy Document, that I understand the same, and that the information I have provided is true and correct to the best of my knowledge. I authorize the facility to act in accordance with the terms stated herein.

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