Name of Insurance or Lien policy holder:
I, (Patient's name) First Name Last Name give my permission for South Pointe Healthcare At Coal Creek, to release the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section II of this document.
Who Can Receive My Health InformationI give authorization for the health information detailed in section II of this document to be shared with the following individual(s) or organization(s).Name: Organization:
I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them. I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:
Name: South Pointe Healthcare
Address: 160 Old Laramie Trail Suite 210, Lafayette, CO. 80027
In the event that my personal information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.
I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
Printed Name: First Name Last Name Date:
If this form is being completed by a person with legal authority to act an individual's behalf, such as a parent or legal guardian of a minor or health care agent, please complete the following information:Name of person completing this form: First Name Last Name
Patient Responsibility: Patient understands that it is his/her obligation to know his/her insurance requirments and ensure that they have been fulfilled, including having a valid authorization for service in place prior to his/her Medical services South Pointe Healhcare will check for eligibility as a courtesy, however this is not a guarantee of payment/coverage by the insurance company. Insurances that fail to pay for claims filed, regardless of the reasoning, will lead to the Patient and/or Guarantor being responsible for payment of the remaining uncovered charges. Insurance has to be present and active at the time of service, along with a valid U.S issued photo identification. If insurance information is presented after treatment we will file a claim to your insurance company on your behalf. However, you will be held liable for the charges if the insurance denies the claim because of late presentation of coverage or for lack of timely authorization due to late presentation of coverage.
Insurance Payments: We participate with most insurance plans in the area. Some services may not be covered by your insurance policy. Your insurance coverage is a contract between you and your insurance plan. Co-payment, deductibles, co-insurances and servicees are not coveered by your insurance plan or outstanding balances are all patient's responsibility to pay in full.
Co-Payments are due at the time of service: It is your contractual obligation with you insurance company to pay the copay portion of the visit at time of service. Patients unable to pay their copay, will have their appointment rescheduled.
Missed Appointments: We charge a $50.00 fee for any office appointments missed or cancelled under 24 hour's notice. Late appointments and same day reschedules are considered missed appointments and are subjected to a missed appointment fee. These fees are patient responsibility and will not be submitted through insurance or liens.
Medical Records: We offer patient free electronic records via a secure email. You will be subjected to a fee for any printed records. We wll fax all records for free to any Physician's office or other medical facuility as a courtesy. A signed HIPAA authorization will be required to send your records to any third party requester.
Past Due Balances: After 90 days your account will be considered past due and can be turned over to a third-party collection agency. If it becomes necessary to turn your account over to a third-party collection agency due to your non-payment you will be dismissed from the practice. We ask that you handle any outstanding balances within 90 days. Please reach out to our billing department or Practice Manager for needed payment arrangements.
Self-Pay: Patients who are not billing a third party or health insurance must pay in full at the time of servce.
Your signature on this page constitutes as an acknowledgement and understanding of this policy. I have read and agree to the above policies and authorize payment directly to South Pointe Healthcare.Date: mm/dd/yyyy
Consent Related to Privacy Notice:
I have had a chance to review the Practice Privacy Notice as paart of this registration process. I understand that the terms of the Privacy Notice may change and I may need to obtain these revised notices by contacting the practice by phore or in writing. I understand I have the right to request how my protected health information )PHI) has been disclosed. I also have the right to restrict how the information is disclosed, but this practice is not required to agree to my restrictions. IF it does agree to my restrictions on PHI use, it is bound by that agreement.
Consent For Care:
I, with my signature, authorize South Pointe Healthcare, and any employee working under the direction of the physician, to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services nad supplies realted to my health (or the identified person) and may include (but not limited to) preventative, diagnostice, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function ofthe body and the sale of dispensing of drugs, devices, equiptment 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.
By signing this I agree that I have read and understand the Consents as above stated:Patient name if different from Responsible Party: First Name Last Name Date: mm/dd/yyyy
Name: First Name Last Name Date of Birth: mm/dd/yyyy
I confirm that I DO NOT have any Government issued or Commercial insurance. Per Government guidelines and our contractual agreement with the insurance Companies, South Pointe Healthcare must bill insurances before accepting self-pay
I understand that if I withhold any active insurance information I may be discharged or Initial reported for fraud
I understand that all payments for services rendered are due at the time of my Initial appointment or my appointment may be rescheduled.
Printed Name of Patient or Personal Representative: First Name Last Name Date: mm/dd/yyyy