General Medical Care Consent
TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.
You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions. I voluntarily request a physician, and/or mid-level provider (nurse practitioner, physician assistant, or clinical nurse specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Record Release Request
I hereby authorize all my personal medical records to be forwarded to AFP Health for continuity of care.
AFP Health3180 Willow LaneSuite 102Westlake Village, CA 91361
Fax: (805) 557-0196Email: email@example.com
Please either mail, fax or email records to our office. Your promptness and cooperation is greatly appreciated.
Dr. Bader IqbalDr. Zoya FurmanDr. Aamir Iqbal
HIPAA EMAIL CONSENT FORM
HIPAA stands for Health Insurance Portability and Accountability Act. HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information. Information stored on our computers is encrypted.
Most popular email services (ex. hotmail, gmail, yahoo) do not utilize encrypted email.
When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is trnasmitted over the internet. In addition, once the email is received by you, someone may be able to access your email account and read it.
Email is a very popular and convenient way to communicate for many people so in their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA. The information is available in a PDF (page 5634) on the U.S. Department of Health and Human Services website (http://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01073.pdf).
The guidelines state that if a patient has been made aware of the risks of unencrypted email and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.
24 Hour Cancellation & "No Show" Fee Policy
Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, AFP Health reserves the right to charge a fee of $35.00 for all missed appointments ("No shows") and appointments that are not cancelled with greater than a 24 hour advance notice.
"No Show" fees will be billed to the patient. This fee is not covered by insurance and must be paid prior to your next appointment. Multiple "no shows" in any 12 month period may result in termination of our relationship.
Thank you for your understanding and cooperation as we strive to best serve the needs of all of our patients.
By signing below, you acknowledge that you have received this notice and understand this policy.
Additional Office Visit Billing Policy
Physical Visit and Office Visit on Same Day: The annual physical appointment covered by your insurance is a "Preventative Care Service" provided by your physician. This visit is intended to review your upcoming preventative services and complete a physical exam. This visit has no copay associated with is and is covered by your insurance. However, if during your annual physicial you also have an acute complaint that needs medical attention or need adjustdments to your chronic medical problems, then you will also be billed for a regular office visit. This portion of the office visit does have a copay associated with it like all your other regular office visits. You may see a charge for both the "Annual Physicial" and "Office Visit" on your insurance bill. These are two seperate services provided by your physician and are billed in such a manner. The alternative to this is to not discuss any medical problems while you are here and have you follow up on another day for your acute complaints. As a courtesy to you and to not have you come back multiple times to the office we combine these visits into the same day to avoid delays in care and create more convinence for you.
Telehealth Appointments: Due to COVID-19, we now have transitioned many of our follow up appointments to Telehealth visits such as phone calls or video calls. This is in an effort to comply with state and federal regulations as well as create a safe and healthy environment for all our patients. These visits are billed as regular office visits since they are replacing an in person visit. Depending on your insurance there may be a deductible or copay associated with this visit. We will continue to offer these services as long as possible and follow the guidelines provided by your insurance company for approriate billing.
Financial Communications Consent
I acknowledge, that as a courtesy, the practice may bill my insurance company for services provided to me.
I agree to pay for services that are not covered or covered charges not paid in full including, but not limited to any co-payment, co-insurance and/or deductible, or charges not covered by insurance.I understand there is a fee for returned checks.
Third Party Collection: I acknowledge the practice may use the services of a third-party business associate or affiliated entity as an extended business office (“EBO Servicer”) for medical account billing and servicing.
Assignment of Benefits: I hereby assign to the practice any insurance or other third-party benefits available for health care services provided to me. I understand the practice has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to the practice, I agree to forward all health insurance or third-party payments that I receive for services rendered to me immediately upon receipt.
Medicare Patient Certification and Assignment of Benefit: I certify that any information I provide, if any, in applying for payment under Title XVIII (“Medicare”) or Title XIX (“Medicaid”) of the Social Security Act is correct. I request payment of authorized benefits to be made on my behalf to the practice by the Medicare or Medicaid program.
Consent to Telephone Calls for Financial Communications: I agree that, in order for the practice, or Extended Business Office (EBO) Servicers and collection agents, to service my account or to collect any amounts I may owe, I expressly agree and consent that the practice or EBO Servicer and collection agents may contact me by telephone at any telephone number, without limitation of wireless, I have provided or the practice or EBO Servicer and collection agents have obtained or, at any phone number forwarded or transferred from that number, regarding the services rendered, or my related financial obligations. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.
A photocopy of this consent shall be considered as valid as the original.