PHYSICIAN’S RELEASE AND ASSIGNMENTS

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES INCURRED BY ME, AND I AGREE THAT IN THE EVENT THAT THIS ACCOUNT IS REFERRED TO COLLECTIONS, I WILL PAY ALL THE COLLECTION EXPENSES, ATTORNEY FEES, AND COURT COST.

 

I HEREBY AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION REQUIRED BY MY INSURANCE CARRIER (S).  A COPY OF THIS AUTHORIZATION MAY BE USED IN LIEU OF THE ORIGINALS.  I FURTHER AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION AND HEALTH CARE FINANCING ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM.

 

I REQUEST PAYMENT OF MEDICAL INSURANCE BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR CHARGES NOT COVERED BY THIS AUTHORIZATION, AND I AGREE THAT IN THE EVENT THAT THIS ACCOUNT IS REFERRED TO COLLECTIONS, TO PAY ALL COLLECTION EXPENSES, ATTORNEY FEES, AND COURT COSTS.

LA LIBERACION DE MEDICO Y TAREAS

YO COMPRENDO QUE SOY FINANCIERAMENT RESPONSABLE POR TODOS LOS CARGOS CONTRAIDOS POR MI, Y YO CONCUERDO QUE EN EL CASO QUE ESTA CUENTA SE REFERIDA A COLECCIONES, YO PAGARE TODOS LOS GASTOS DE COLECCIÓN, Y TODOS LOS GASTOS DE ABOGADO Y LOS COSTOS DE LA CORTE.

 

POR MEDIO DE LA PRESENTE Y COMO FUERS SOLICITADO POR MI COMPANIA DE SEGURO, CONCEDO ACCESO A CUALQUIER INFORMACION EN REFERENCIA A MI HISTORIAL CLINICO. UNA COPIA DE ESTA AUTORIZACION PUEDE SER USADA EN LUGAR DE LA ORIGINAL. PARA FINES DE SERVICIOS DE MEDICARE AUTORIZO A CUALQUIERA EN POSESION DE DICHA INFORMACION EL PODER DE COMPARTIRLA CON LA ADMINISTRACION DEL SEGURO SOCIAL Y LA ASOCIACCION FINANCIERA DE ADMINISTRACION DE LA SALUD Y SUS INTERMEDIARIOS O DISTRIBUIDORES.

 

A SU VEZ SOLICITO EL PAGO DE BENEFICIOS DE SEGURO MEDICO A MI MISMO O A UN TERCERO. COMPRENDO QUE SOY RESPONSIBLE FINANCIERAMENTE DE LOS CARGOS NO CUBIERTOS POR ESTA AUTORIZACION Y POR CARGOS AN ABOGADOS Y CORTES, EN CASO DE QUE ESTA CUENTA SEA REFERIDA A RECAUDADORES.

IF YOU DO NOT KNOW THE INFORMATION PLEASE WRITE “DO NOT KNOW” ON THE LINE PROVIDED (SI USTED NO SABE LA INFORMACIO POR FAVOR ESCRIBA “NO LO SE” EN LA LINEA)

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE

(Yo Certifico Que La Información De Encima Esta Completa y Correcta.)

CONSENT FOR THE USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

I HEREBY GIVE CONSENT TO NIRMAL NATHAN, M.D., P.A., AND ALL HEALTH CARE PROVIDERS FURNISHING CARE WITHIN THE PRACTICE TO USE AND DISCLOSE MY PROTECTED HEALTH INFORMATION FOR THE PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.

 

MY “PROTECTED HEALTH INFORMATION” MEANS THAT HEALTH INFORMATION, INCLUDING MY DEMOGRAPHIC INFORMATION, COLLECTED FROM ME AND CREATED OR RECEIVED BY MY PHYSICIAN, ANOTHER HEALTH CARE PROVIDER, A HEALTH PLAN, MY EMPLOYER, OR A HEALTH CARE CLEARINGHOUSE.  THIS PROTECTED HEALTH INFORMATION RELATES TO MY PAST, PRESENT, AND FUTURE PHYSICAL AND MENTAL HEALTH CONDITION. IT IDENTIFIES ME OR THERE IS A REASONABLE BASIS TO BELIEVE THE INFORMATION MAY IDENTIFY ME.

 

PLEASE BE ADVISED THAT OUR NOTICE OF PRIVACY PRACTICES PROVIDES MORE DETAILED INFORMATION ABOUT HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION.  YOU HAVE THE RIGHT TO REVIEW OUR NOTICE OF PRIVACY PRACTICES BEFORE YOU SIGN THIS CONSENT. WE RESERVE THE RIGHT TO REQUEST AND RESTRICT HOW WE USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR THE PURPOSES OF TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS.  WE ARE NOT REQUIRED TO GRANT YOUR REQUEST, BUT IF WE DO, THE RESTRICTION WILL BE BINDING ON US.

 

YOU MAY REVOKE THIS CONSENT AT ANY TIME.  YOUR REVOCATION MUST BE IN WRITING, SIGNED BY YOU OR ON YOUR BEHALF, AND DELIVERED TO THE ABOVE ADDRESS.  YOU MAY DELIVER YOUR REVOCATION BY ANY MEANS YOU CHOOSE BUT IT WILL BE EFFECTIVE ONLY WHEN WE ACTUALLY RECEIVE THE REVOCATION.  YOUR REVOCATION WILL NOT BE EFFECTIVE TO THE EXTENT THAT OTHERS ARE OR WE HAVE ACTED IN RELIANCE UPON THIS CONSENT.

CONSENTIMIENTO PARA EL USO Y/O REVELACION DE LA INFORMACION DE SALUD PROTEGIDA

YO LE DOY CONSENTIMIENTO A EL DOCTOR NIRMAL NATHAN, M.D., P.A. Y A TODA SU ASISTENCIA MEDICA DE PROVEEDORES QUE PROPORCIONAN EL CUIDADO MEDICA DENTRO DE LA PRACTICA PARA UTILIZAR Y REVELAR MI  INFORMACION DE SALUD PROTEGIDA PARA EL PROPOSITO DE LOS TRATAMIENTOS, PAGOS Y PARA LAS OPERACIONES DE ASISTENCIA MEDICA.

 

MI “INFORMACION DE SALUD PROTEGIDA” INCLUYENDO MI INFORMACION DEMOGRAFICA QUE FUE ENTREGADA Y CREADA POR MI Y RECIBIDA POR MI MEDICO, POR OTRO PROVEEDOR DE ASISTENCIA MEDICA, POR UN PLAN DE SALUD, POR MI EMPLEADOR, O POR UN BANCO DE LIQUIDACION DE ASISTENCIA MEDICA. ESTA INFORMACION PROTEGIDA DE SALUD ES RELACIONADA A MI PASADO, PRESENTE, Y EL FUTURO DE MI SALUD FISICA O CONDICION MENTAL DE SALUD. ME IDENTIFICA, O HAY UNA BASE RAZONABLE DE CREER QUE LA INFORMACION ME IDENTIFICA.

 

ESTA USTED ACONSEJADO QUE NUESTRA NOTA DE PRACTICAS DE INTIMIDAD PROPORCIONA INFORMACION MAS DETALLADA SOBRE COMO NOSOTROS UTILIZAMOS Y REVELAMOS SU INFORMACION DE SALUD PROTEGIDA. USTED TIENE EL DERECHO DE REVISAR NUESTRA NOTA DE PRACTICAS DE INTIMIDAD ANTES DE FIRMA ESTE CONSENTIMIENTO. RESERVAMOS EL DERECHO DE SOLICITAR Y RESTRINGIR COMO NOSOTROS UTILIZAMOS Y REVELAMOS SU INFORMACION  DE SALUD PROTEGIDA PARA EL PROPOSITO DE EL TRATAMIENTO, DE EL PAGO, O DE LAS OPERACIONES DE ASISTENCIA MEDICA.

 

USTED PUEDE  REVOCAR ESTE CONSENTIMIENTO HA CUALQUIER HORA. SU REVOCACION DEBE ESTAR EN ESCRITO, FIRMADA POR USTED O EN SU BENEFICIO, Y ENTREGADA A LA DIRECCION QUE ESTA ENCIMA. USTED PUEDE ENTREGAR SU REVOCACION POR CUALQUIER MEDIO QUE USTED ESCOGA, PERO SERA EFECTIVO SOLO CUANDO NOSOTROS RECIBIMOS REALMENTE LA REVOCACION. SU REVOCACION NO SERA EFECTIVA HASTA EL PUNTO QUE OTROS HAN ACTUADO O EN LA DEPENDENCIA SOBRE ESTE CONSENTIMIENTO.

 

All Insurance Patients – Signature on File

I request that payment of authorized benefits be made on my behalf to the provider for any services furnished me. I authorize any holder of medical information about me to release to the above-listed insurance companies and their agents any information needed to determine these benefits payable for related services.

Medicare Patients Only – Medicare Signature on File

I request that payment of authorized Medicare benefits be made on my behalf to the provider for any services furnished me. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services. I understand my signature requests that payment be made and authorizes the release of medical information necessary to pay the claim. If “other health insurance” is indicated in Item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes the release of the information to the insurer or agency shown. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier.

YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE

UNDER FLORIDA LAW, PHYSICIANS ARE GENERALLY REQUIRED TO CARRY MEDICAL MALPRACTICE INSURANCE OR OTHERWISE DEMONSTRATE FINANCIAL RESPONSIBILITY TO COVER POTENTIAL CLAIMS FOR MEDICAL MALPRACTICE. THIS IS PERMITTED UNDER FLORIDA LAW SUBJECT TO CERTAIN CONDITIONS. FLORIDA LAW IMPOSES PENALTIES AGAINST NON-INSURED PHYSICIANS WHO FAIL TO SATIFY ADVERSE JUDGEMENTS ARISING FROM CLAIMS OF MEDICAL MALPRACTICE. THIS IS PROVIDED UNDER PURSUANT TO FLORIDA LAW.

SU DOCTOR HA DECIDIDO NO TENER SEGURO DE MALAPRACTICA

BAJO LA LEY DEL ESTADO DE LA FLORIDA, SE REQUIRE QUE LOS DOCTORES EN MEDICINA TENGAN SEGUROS DE MALA PRACTICA O, TENER QUE DEMOSTRAR SER FINANCIERAMENTE REPONSABLES PARA PODER CUBRIR RECLAMOS DE MALA PRACTICA MEDICA. ESTO ES PERMITIDO BAJO LA LEY DE LA FLORIDA BAJO CIERTAS CONDICIONES. LA LEY DE LA FLORIDA IMPONE PENALIDADES A LOS DOCTORES QUE NO ESTEN ASEGURADOS Y QUE NO SATISFAGAN JURISDICCIONES ADVERSAS POR DEMANDAS EN SU CONTRA COMO RESULTADO DE UNA MALA PRACTICA MEDICA. ESTA NOTA ESTA BASADA BAJO LA LEY DE LA FLORIDA.

Preface:
I, Dr. Nirmal Nathan, have decided under Florida Law to practice without Malpractice insurance. Under this practice, this Arbitration Agreement (“Agreement”) should be read carefully and fully understood. If you have any questions before or after reading and signing this statement please ask the staff or my office manager. Please read this document clearly. Thank you for your consideration.

Article 1:
Agreement to Arbitrate: It is understood that my dispute as to medical malpractice that is, as to whether any medical services rendered under this contract were unnecessary, authorized or were improperly, negligently, or incompletely rendered, will be determined by submission to arbitration as provided by the Florida Arbitration Code, Chapter 682, and not by a lawsuit except as Florida law provides for judicial review or arbitration proceeding. Both Parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2:
All Claims Must Be Arbitrated: It is the intention of the parties that this Agreement bind all parties whose claims may arise out if related treatment or services provided by the physician including any spouse or heir of the patient or any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of a pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners, associate, association, corporation or partnership, and the employees, agents and estates of any of them must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filling of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3:
Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties and must be within the time frame set forth in F.S.95.11 dealing with medical malpractice. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of demand for neutral arbitrator by either party. Each party to the arbitration shall pay such party’s prorated share of the expenses and fees to the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. Arbitration shall take place within 30 days after the completion of discovery as provided in the Florida Rules of Civil Procedures (Rules 1.0280-1.0390) and the decision of the arbitration panel shall be binding upon the parties for all purposes. The time to responding to discovery requests shall be 10 days. All discoveries shall be completed within 2 months after the appointment of the panel of arbitrators, unless the time for the discovery is extended for good cause by the panel. The arbitration panel shall decide any disputes regarding discovery. The arbitration panel is expressly authorized to award all reasonable fees and costs, including attorney’s fees, to the prevailing party against any part who has violated this Agreement. The parties agree that the arbitrators have the immunity of a judicial officer for civil liability when acting in the capacity of arbitrator under this contract. The immunity shall supplement, not supplant, any other applicable statutory or common law provisions. Either party shall have the absolute right to arbitrate separately the issues of liability and damages, upon written request to arbitrate separately the issues of liability and damages, upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be proper additional party in court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

Article 4:
General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in on proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in civil action, would be barred by the applicable Florida statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for the arbitrator shall be governed by the Florida Rules of Civil Procedure provisions relation to arbitration.

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect and shall not be affected by the invalidity of any other provisions.