2021 Consent Form

These notification will be used to send appointment reminders. They will never be used for marketing or spam. Note: By providng the above information, you allow us to contact you at these telephone numbers and addresses. 

Authorizations & Rights

Authorization for Medical Treatment: I authorize the physician(s), psychologist(s), therapists(s), their assistants and/or designees in charge of my medical care to administer any treatment as may be necessary or advisable in my diagnosis and treatment at Alivation Health, L.L.C., ("Facility). This authorization includes, but is not limited to, routine diagnostic procedures, rehabilitation therapy, laboratory tests, and the use of prescription medication. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to results of examination and treatment received at this Facility. I acknowledge that my care is under the direction of my treating physician(s) and the Facility will follow the instructions of my physician(s) in the provision of said care.
Statement of Responsibility: I understand that I am financially responsible to the Facility(s) as the patient, parent, guardian, conservator or insured for all charges not covered by the above assignments. Charges may include medical insurance deductibles, co­ insurance, or out-of- pocket expenses.
Notice of Privacy Practices: I have been given the opportunity to review the Facility's Notice of Privacy Practices for Protected Health Information. I understand that the Facility has the right to change the Notice of Privacy Practices at any time, and that I may obtain a current copy at the Facility's office during normal business hours.
Patient Rights & Responsibilities: I have been given the opportunity to review the Facility's Patient Rights & Responsibilities. I understand that the Facility has the right to change the Patient Rights & Responsibilities at any time, and that I may obtain a current copy at the Facility's office during normal business hours.
Magellan Member Rights & Responsibilities: I have been given the opportunity to review the Magellan Member Rights & Responsibilities and I understand that I may obtain a current copy at the Facility's office during normal business hours.
 

Payment & Insurance

I authorize Alivation Health, L.L.C. to release to the Insurance carrier(s) provided any medical information needed for authorization or payment of this or a related claim. I also authorize payments directly to this office for the health benefits. I understand that I am responsible for all pre-authorizations required by my insurance. Furthermore, I understand that I am financially responsible for all charges.

For the benefit of our patients, Alivation Health is contracted with most insurance companies. We accept cash, checks and credit cards (Visa, Discover, and MasterCard). Some services we offer, such as school physicals and weight management services, may not be covered by insurance. Insurance coverage varies based on each patient's individual insurance plan.

Monthly Billing Statements: Every month our office sends out a monthly billing statement to every patient. The balance due is the remainder owed after your insurance has paid.

Copayments: Copays are due at the time of service, if you are unable to pay at the time of service you may need to reschedule your visit. If your visit will not take place in the clinic you may be asked to pay your Copay at time of scheduling.

Insurance Cards: Insurance cards are required at every visit. If you have not provided our office with the correct insurance information, you will be responsible for any balance due.

Self-Pay Patients: If you do not have insurance, your balance is due at the time of your office visit. If you are unable to pay at time of service, you may be asked to reschedule.

Payment Plans: If you have negotiated a payment plan with us, you are responsible for making timely and consistent monthly payment s. If you fail to make your scheduled due date, your account will be sent to collections for non­payment.

Screening Labs: If a screening lab is done, some of the charges from the lab may be applied to your deductible. Please speak with the provider if you would like a limited lab draw instead of the recommended full screening lab.

Late Arrival: If you arrive more than 15 minutes late, we may need to no-show your appointment & reschedule or we may ask that you wait until the next open spot in the schedule while we continue to see the patients who arrived on time.

No-Show Fees: I have been advised that this office requires a 24-hour prior notice on all appointment cancellations. I have been advised that there will be a no-show fee for appointments that are canceled with less than 24-hours' notice. This fee is not covered by any insurance plan. Fee varies based on appointment type missed and are updated from time to time.

Collections: If your account balance is unpaid and overdue after three attempts to contact you, and you have not responded to any of our attempts to contact you, your account will be referred to a collection agency. Once your account is in collections, you will be dismissed from our practice, which includes refill requests and appointments.

Pre-Authorization for Mental Health Services: Most insurance companies require pre-authorization for mental health services, prescription medications, and certain medical treatments. We strongly encourage you to contact your insurance to inquire about any pre-authorization requirements. You may also want to obtain information regarding your health benefits. Most often, health insurance benefits for mental health are different from the benefits for general healthcare. Please contact our billing office should you have any questions regarding the information from your insurance.

Appointments

We see patients by appointment and offer same-day appointments for patients with acute needs. If you call our office outside of regular business hours with a medical concern, you will be prompted to leave a message for the on-call provider who will triage those calls who may call back if deemed necessary.

Providers: To ensure you receive the best care, your provider may change during treatment. Reasons for this may include insurance changes, provider specialty, or provider availability.

Staff: Our staff will treat all patients with the upmost respect and professional attitude. In return, we expect our patients to be courteous in our office. If a patient is consistently uncooperative, refuses to follow treatment plans, or uses demanding and abusive language our staff have the right to dismiss a patient from our practice for non-compliance.

Appointment Norms: Due to healthcare regulations and time constraints, providers may address only one or two concerns each visit. Please prioritize your concerns each visit. You may schedule another visit regarding any further concerns.

Lab, Tests, and Procedure Norms: Please schedule a follow up appointment each time a test is performed, or a lab test is ordered. Results are usually received 7-10 days after the test is completed. We are not able to provide you with the results of labs, x-rays, MRI etc. without an appointment.

Physicals, Well Child Checks, Pre-Ops, and other Preventative / Screening Visits: Providers are unable to discuss new problems at Preventative and Screening Visit types. You may be asked to address new issues at a different visit or reschedule your current visit if your other need is urgent. Due to insurance regulations, we are only able to see you for one type of visit per business day.

Prescriptions

Please check your medication supply prior to your visit so we can order refills at the time of your appointment. We process refill requests only during business hours and we require a 72-hour turnaround. You can follow up directly with your pharmacy after 48 hours. We will call you only if we have a question regarding the refill.

Alivation Pharmacy is located onsite and provides bubble-packing, consultation services, delivery service and mail service. Alivation Pharmacy is in network with most insurances and can take medications from both your Alivation provider and your external providers.

Prescription Refill Requests: Medications will only be filled during an appointment with your provider. It is important that we closely monitor your medication. If you need a refill prior to your next scheduled appointment, we require that you schedule a sooner appointment prior to receiving a prescription refill. If a refill is provided, it will only cover the days until your regularly scheduled appointment. If you miss your appointment, no refills will be given, until you schedule and attend a new appointment.

Medication Lists: Please bring all medications with you to all appointments. This allows our providers to not only review the medications that our office is prescribing, but also to review medications taken over the counter on a regular basis and medications prescribed by other providers. Also please notify your provider if there have been any medication changes since your last visit. Note- these medications may not be reviewed at each visit but are there if the provider needs them.

Controlled Substances: Any medication that is considered a controlled substance will require an appointment for refills. These patients will need to be seen every 4 weeks if they are only doing medication therapy, or if you are compliant with our EEG Protocols, you may be seen up to every 8 weeks. These appointments are necessary to check appropriate lab levels, brain health monitoring, monitor usage and effects closely, as well as provide Next Level Care. Examples of Controlled Substances: Sleep Aids, Anxiety Relief, Pain Relief, ADHD Medication

Note: Alivation has a policy against prescribing chronic narcotic medications for chronic pain. If you have a chronic pain condition, we will refer you to a pain management specialist.

Medical Records

Your medical records are strictly confidential. We are prohibited from releasing any information from your records without your express written permission. Please allow five to seven business days for us to complete any requested forms, prior authorizations, or letters. By law we must respond to a request within 30 days. Be advised that some forms and letters may require an office visit or have a pre-paid fee to complete them.

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8550 Cuthills Circle Lincoln, NE 68526 | alivation.com | info@alivation.com

Behavioral Health | Phone: 402.476.6060 | Fax: 402.476.6809

Primary Care | Phone: 402.466.3355 | Fax: 402.466.3410