CONSENT FOR MEDICAL TREATMENT
I, the patient or the authorized representative of the patient, hereby consent to any examination, evaluation and treatment provided for any illness, injury, or other health concern affecting me at any time I present at Community Healthcare Partners for medical care. These services may include but are not limited to: laboratory procedures, x-ray examinations, review of external pharmacy information and medical and/or surgical treatment or procedures.
• All patients must provide accurate and complete personal and insurance information prior to being seen by the physician, physician assistant, nurse practitioner or other medical care provider/practitioner.
• Payment is required at the time of service. Community Healthcare Partners (CHP) accepts payment by cash, check and credit/debit card.
• CHP will file a claim with your insurance company; however, it is your responsibility to comply with all predetermination, pre-authorization and/ or notification requirements as may be required by your insurance plan. While many of the services provided by CHP may be covered benefits of your insurance plan, how these benefits are paid by your insurance provider and/or whether or not certain services are considered to be non-covered services is determined strictly by your insurance provider and not by our office. It is your personal responsibility to understand the limitations and exclusions of your insurance plan, as well as to understand your co-pays, deductibles, in-network and out of network coverage including any and all applicable limitations, inclusions and/or exclusions.
• Community Healthcare Partners requires that the guarantor agree to be personally liable for all balances due or that may become due related to today’s visit.
• The fees for our services are reasonable and customary fees for this region and specialty. If the patient’s insurance company reimburses at a different rate than what is billed by Community Healthcare Partners, the patient may be responsible for any balance remaining.
• We may charge reasonable fees for services related to your account including, but not limited to, returned check fees, interest on unpaid accounts, and medical record copies.
• Should it be necessary to forward an account balance to a collection agency, the guarantor agrees to assume financial responsibility for reasonable collection costs.
• Community Healthcare Partners may disclose all or part of a patient's medical or financial records (including information related to alcohol and drug abuse, mental health diagnosis and treatment, HIV related or other communicable disease related information) to third parties to obtain payment for services provided.
• The patient’s personal information will be updated at least one time per year to verify the information on file is accurate. It is the responsibility of the patient to notify our office of any changes of the personal and/or insurance information provided on this form.
• Federal laws require that Community Healthcare Partners submit every claim to an insurance company accurately and report the exact services performed and the exact reason for performing them. It is insurance fraud to change this information in order to try to obtain payment on a claim from an insurance company.
• I understand and agree that any cellular or landline phone numbers and email addresses provided by myself to this office and to any of our service providers, now and in the future, may be used as a means to contact me, and that this office and our service providers may leave messages for me manually and by using automatic systems such as by artificial or prerecorded voice or text and disclose the nature of communication. In the future, should I acquire a new or different cellular, landline or email address, I agree that this consent would stay effective.
I agree that in the event my insurance provider does not pay for some/all of the charges associated with and incurred for today’s visit, I will pay any remaining balance due and that balance will be my personal financial responsibility. I understand that this only applies to Community Healthcare Partners procedures and charges and that this excludes any and all charges incurred from third party entities as a result of laboratory testing, durable medical equipment, etc. I understand that this Medical Treatment and Financial Agreement is and will be valid for any and all services provided by Community Healthcare Partners effective from the date this Medical Treatment and Financial Agreement is signed by me and does not expire unless and until I inform our office directly that I no longer wish to have this Medical Treatment and Financial Agreement in effect.
I have been given the opportunity to read the office’s Notice of Privacy Practices and have had any questions addressed concerning that policy.