PATIENT CONSENT FORM

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I hereby give my consent for ROCK CREEK FAMILY MEDICINE to use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). (ROCK CREEK FAMILY MEDICINE’s Notice of Privacy Practice provides a more complete description of such uses and disclosures.)

I have the right to review the Notice of Privacy Practice prior to signing this consent. ROCK CREEK FAMILY MEDICINE reserves the right to review its Notice of Privacy Practice at any time. A revised Notice of Privacy Practice may be obtained by forwarding a written request to ROCK CREEK FAMILY MEDICINE at 77 ADCOCK DRIVE, ALAMOSA, COLORADO 81101.

With this consent, ROCK CREEK FAMILY MEDICINE may email or mail to my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any calls pertaining to my clinical care, including laboratory or other testing results.

By signing this consent, I am consenting to ROCK CREEK FAMILY MEDICINE’s use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, ROCK CREEK FAMILY MEDICINE may decline to provide medical treatment to me.

RECEIPT OF NOTICE OF PRIVACY PRACTICE WRITTEN ACKNOWLEDGEMENT FORM

This is a short summary of the Notice of Privacy Practice. If requested, you may obtain a copy of the 147 page booklet.

We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.

Although your health record is the physical property of the healthcare practitioner of the facility that compiled it, the information belongs to you. You have the right to:

• Request a restriction on certain uses and disclosures of your information
• Obtain a paper copy of the Notice of Privacy Practice upon your request
• Inspect and obtain a copy of your health record
• Request an amendment to your health record
• Obtain an accounting of disclosures of your health information

I have read the above and understand my options regarding ROCK CREEK FAMILY MEDICINE’s Notice of Privacy Practice.

INSURANCE AUTHORIZATION and ASSIGNMENT

I request the payment of authorized Medicare and/or other insurance company benefits be made on my behalf to ROCK CREEK FAMILY MEDICINE for any services furnished to me by that party which accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply.

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries of carriers any information needed for this or a related Medicare claim and/or other insurance company claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to me or to the party that accepts assignment. I understand it is mandatory to notify the health care provider of any other party that may be responsible for paying for my treatment, (Section 1128B of the Social Security Act and 31 U.S.C. 38/01-3812 provides penalties for withholding this information.)

I request that payment under the Medicare and/or other medical insurance program(s) be made to ROCK CREEK FAMILY MEDICINE for as long as I continue to receive services from them. If I were to receive any checks (payments) intended as payment for services rendered by ROCK CREEK FAMILY MEDICINE FROM Medicare and/or other insurance company, I will immediately endorse them and turn them over to ROCK CREEK FAMILY MEDICINE for services rendered.

I understand that I am responsible for payment of all charges and fees to ROCK CREEK FAMILY MEDICINE to which they are entitled to collect which are not paid for by Medicare and/or other insurance company.

I acknowledge that this office, as a courtesy, will file with my insurance company for its portion of the fees incurred the date of my visit and will credit any such collections to my account. However, I understand that all medical services furnished are charged directly to the patient and that I am personally responsible for payment of all medical services, including any balances not paid by my insurance carrier regardless of the basis for their nonpayment. I know that this office cannot negotiate with my insurance carrier as my policy is a contract between me and/or my employer, and the insurance company. Notifying this office of any change in my insurance coverage is my responsibility.

I understand and agree that I am responsible for any unpaid balance on my account and that a service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, or a $2.00 minimum, which includes any dependents for which I am also responsible.

I have been advised that my account will be referred to a collection agency if the past due balance exceeds 90 days. If your account is over 90 days past due, you will receive a letter stating that you have 14 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. (Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice.) Notice of this referral constitutes notice of intent to discontinue treatment and will automatically release this office of any future medical services to me and my account is then terminated. I will be responsible to pay all collection fees and charges.

We participate in most insurance plans, including Medicare. If you are not insured by a plan we are contracted with, payment in full is expected at each visit. If you are insured by a plan we are contracted with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

All co-payments and deductibles must be paid before your appointment. This arrangement is part of your contract with your insurance company. Also, any balance due on your account is due before your appointment. Please be prepared to make these payments when you come in.

Please be aware that some – and perhaps all – of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit. For example, some insurance plans do not cover for yearly exams or Pap tests. Again, knowing your insurance benefits is your responsibility. If your Insurance Company denies your claim for “not medically necessary” or “non-covered charges” then you are responsible for paying for your account in full.

Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

CONSENT for DIAGNOSTIC and/or THERAPEUTIC PROCEDURES

I hereby consent to and authorize my physician and any other health professional as designated to perform any physical examination and routine diagnostic procedures upon me. I also consent to and authorize my physician to prescribe a therapeutic regime, which I shall follow. Unless I explicitly refuse, I consent that the diagnostic procedure (s) and immunization(s) ordered by my physician be performed on me despite the risks involved and complications that might be involved, which will be explained to me at the time they are ordered.

TEST RESULTS

Please allow our staff 5-7 days to inform you of your test results. They will call you when your results have come in.

REFERRALS

Please allow 5 days advance notice for referrals to physicians outside of our specialty. You are responsible for calling your insurance company to see if a referral is needed for the Dr. or procedure necessary.

PRESCRIPTION REFILLS

Please allow 24 hours advance notice for prescription refills. Please plan ahead for your refills. Please call your pharmacy when you need refills, unless you need a written prescription. If you use a mail order company for your prescriptions, the paper work and mailing is your responsibility, our office will only supply the prescription. A payment of $25.00 will be required upfront for paperwork on any service beyond the supply of the prescriptions.

APPOINTMENT CANCELLATIONS

You are required to give a 12 hour notice of cancellation of an appointment, otherwise you will be billed $60.00, which you are required to pay. Your insurance will not be billed for this charge.

I HAVE READ THE PATIENT CONSENT FORM, THE RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM, THE INSURANCE AUTHORIZATION AND ASSIGNMENT FORM AND THE CONSENT FOR DIAGNOSTIC and/or THERAPEUTIC PROCEDURES FORM. I UNDERSTAND THAT BY SIGNING THE ELECTRONIC SIGNATURE BOX I AM AGREEING TO AND UNDERSTANDING ALL OF THE ABOVE.