Consent to Treatment: Signing this consent means I agree to health care treatment at Neighborhood HealthSource (NHS I understand if I do not sign this consent, NHS cannot provide health care services to me.
Assignment of Insurance Benefits: NHS may bill my insurance or other payer. I ask that insurance payments be made directly to NHS. NHS may share my health and account records with my insurance company or other payers as needed for billing, payment, and claims. NHS may need to share health records for quality reviews and questions from my insurance company. I understand that I am responsible to pay for services and/or supplies not paid for by insurance or other payer.
Authorization to Share Health Information: I understand my information may be shared with or requested by: Health care providers, nurses, hospitals, and other health care centers who give me health care services Clinics where NHS may refer me for health care services (for example, a specialist) Electronic prescribing services My health insurance company or other payer Other companies when required by law
Notice of Health Information Practices: I have seen NHS’s Notice of Health Information Practices. This notice explains my rights and describes how my health information may be shared or used. If I would like a copy, I will ask the staff for a copy.
Electronic Health Information Exchange (HIE): I understand my NHS Health Care Team and other Health Care Teams who treat me may share my information through an HIE. This includes information such as my name, birthdate, health conditions, medicines, allergies, shot records, and lab and other test results.
Appointment and Billing Reminders: I understand NHS may call me or send text messages for appointment, billing and general health care reminders to the phone number I give.
Consent to Communicate by Phone: I understand by providing my telephone number I consent to communication with NHS by phone regarding my health information including but not limited to medical treatment, health checkups, appointments, lab test results, and prescriptions.
Consent to Communicate by Text Message: I understand that text messages are not secure. Messages are at risk of being seen by anyone who gets access to my phone. Text messages may be viewed by my employer if I am using a work phone.
I understand that NHS cannot and does not guarantee the confidentiality of these kinds of messages; that NHS is not responsible for messages that are lost due to technical problems; and that NHS will monitor text messages for appropriate use.
I have read and understand the information about text messages and had any questions answered to my satisfaction.