Responsible Party (Guarantor) Information
(if patient is under 18)
Emergency Contact / Authorization for Release of Information
I authorize Health Professionals of Orthopedics Institute of Central Massachusetts to disclose to a family member, relative, or any other person I have identified below, health information relevant to that person's involvement in my care. I understand you have used your best judgement when disclosing information.
We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies.
- 1) I authorize the physician to release any medical information necessary to process all insurance claims.
- 2) If your insurance company requires a referral to see a specialist and we have not received one, you will be responsible for all charges incurred.
- 3) Keep in mind that your insurance policy is a contract between you and your insurance company.As a service to you, we will file your insurance claim if you assign the benefits to the doctor-in other words, if you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment. If we later receive a check from your insurer, we will refund any overpayment to you.
- 4) We have made prior arrangements with many insurance companies and other health plans to accept an assignment of benefits. We will bill them, and if your insurance company requires a co-payment, it is due at the time of your visit.
- 5) Not all insurance plans cover all services. In the event your insurance plan determines a service to be "not covered," you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.
- 6) Re: Motor Vehicle/ Personal Injury Claims- This office does not take care of patients that have been in motor vehicle accidents or slip and fall (personal injury claims) without express prior approval by the physician. This is something that needs to be arranged in advanced. If it comes up that there is a slip and fall or motor vehicle accident etc. when it was originally booked as a regular referral, then the appointment will be cancelled and all co=payments will be refunded if collected.
I have read and understand the practices financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.
Notice to Patient
By signing this form, you grant us consent to use and disclose your protected health care information for the purposes of treatment, various activities associated with payment and health care operations. Our notice of Privacy Practices provides more details on our treatment, payment activities and health care operations. If there is not a copy of the Notice accompanying this Consent form, please ask for one. We encourage you to read it since it provides details on how information about you may be used and/ or disclosed and describes certain rights you have regarding your health care information.
As stated in out Notice of Privacy Practices, we reserve the right to change our privacy practices. If we should do so, we will issue a revised Notice. Since revisions may apply to your health care information, you have the right to receive a copy by contacting our Privacy Officer.
You have the right to revoke your Consent by giving written notice to our Privacy Officer. The revocation will not affect actions that were already taken in reliance upon this Consent. You should also understand that if you revoke this Consent we may decline to treat you.
You are entitled to a copy of this Consent Form after you have signed it.
have read the contents of this Consent Form and the Notice of Privacy Practices. I understand that I am giving you my consent to use and disclose my health care information to carry out treatment, payment activities and health care operations.
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