Consent Related to Privacy Notice:I have had a chance to review the Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing. I have had a chance to review the Health Information Exchange Notice and understand that Maready Medical participates in the statewide Health Information Exchange program. I understand that I have the right to request how my protected health information (PHI) has been disclosed and have the right to restrict how this information is disclosed. My request must be submitted in writing to the practice, but the practice is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it will be bound by that agreement. A copy, electronic copy, image or facsimile of this authorization is as valid as the original.
Consent for Care:I, with my signature, authorize Maready Medical, and any employee working under the direction of the clinicians, to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services and supplies related to my health (or the identified person) and may include, but not limited to, preventive, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment, though state and federal laws may restrict redisclosure of HIV/AIDS information, mental health information, drug/alcohol conditions, or genetic information.
Consent for Release of Information and Assignment of Benefits:I also authorize this practice to furnish information to the identified insurance carrier(s) for any and all payment activities. I consent to assign all payments for services directly to this practice. I further consent to the use for any practice operational needs as identified in the Practice Privacy Notice.
Your signature below confirms that you have read and understand the Consent for Treatment Policy as stated above.
We will adhere to these policies and would like assurance that you are in agreement before establishing care with us.
We want you to understand how billing for preventive visits work. We feel this is a very valuable resource, as these services are often available to you with no co payment or effect on your deductible.
For any of our services, you agree to be responsible for any charges not covered by your insurance.
Thank you for your understanding and cooperation with this policy. We consider it a privilege to provide your medical care.
Your signature below indicates that you have read and understand this Financial Policy and agree to accept full responsibility as described.