CONSENT FORMS

CONSENT FORMS
Please complete all pages. Each page is a separate consent form.

Please read all of the information contained in each form before signing.

Each of these forms must be filled out prior to being seen at our office.

Please make sure to click the SUBMIT button on the last page

SUMMARY NOTICE OF HIPAA PRIVACY PRACTICES
This notice describes how your medical information may be used and disclosed and you may obtain this information. Please review it carefully.

SUMMARY OF YOUR PRIVACY RIGHTS

We may share your health information to:
- Provde medical care
- Obtain payment
- Manage Health Care Operations
- Administer your care
- Inform you of other health benefits and services
- Provide appointment reminders, treatment alternatives, and health related benefits and services
- Release information to family and friends indicated by you
- Participate in medical research studies
We may use your health information for:
- Health and safety reasons
- Business associates
- Organ and tissue requests
- Military and national security reasons
- Inmates or individuals in custody
- Data breach Notifications Purposes
- Worker’s compensation requests
- Litigations
- Law enforcement requests
- Coroner, medical examiners or funeral director use
Your rights:
- Inspect and copy
- An electronic copy of Electronic Medical Records
- Be notified of a breach
- Have your medical record reviewed and corrected if necessary
- Obtain a list of whom we share your health information
- Ask us to limit the information we share
- Not disclose information for Out of Pocket Payments
- Request confidential communications
- Ask for a copy of our privacy notice
- File a complaint in writing to HOAONC if you believe your privacy rights have been violated by us
I acknowledge that a copy of the Notice of Privacy Practices is available for my review and a copy of this notice is also available upon request and that HOAONC reserves the right to change the term of this notice and that I will be notified of any amendments to the current notice at subsequent visits as needed. If I have any questions pertaining to the current notice, I can contact the Executive Director.
Patient or Legally Authorized Individual's Signature*

Clear
Patient Name:*
First and Last Name
Date*

MonthDayYear
Date
If Signed on Behalf of Patient, Relationship to Patient

Clear

CONSENT FOR ELECTRONIC MEDICATION HISTORY ACCESS
We are currently using electronic prescriptions and ask for you to grant us permission to access your medication history electronically.

Electronically accessing your medication history allows us to receive critically important information on your current and past prescriptions and to become better informed about potential medication issues. We can use this information to improve safety and quality.

By signing below, I give my consent for Hematology and Oncology Associates of Northern California to access my medication history electronically.
Consent for HOAONC to Fill Prescription(s)
I acknowledge that Hematology and Oncology Associates of Northern California has offered written prescription(s) that I may chose to have filled by HOAONC or by any pharmacy of my choice.*

Yes, I choose to have these prescriptions filled by HOAONC with the understanding that I am under no obligation to do so.No, I do not elect to have these prescriptions filled by HOAONC.
Patient Name:*
First and Last Name
Patient DOB:*

MonthDayYear
Date
Signature*

Clear
If signed on behalf of patient, Print Name:
Relationship to Patient:

CONSENT FOR PATIENT PHOTOGRAPHY
I understand that my photograph is being taken for identification purposes only. I understand that Hematology and Oncology Associates of Northern California will retain ownership rights to these photographs and they will become a permanent part of my medical record for as long as that medical record exists. Images that identify me will be released only upon written authorization from me or my legal representation.
I hereby give my consent to be photographed:*

YesNo
Patient Signature:*

Clear

PATIENT PORTAL: MY CARE PLUS
User Electronic Mail Authorization Form
My Care Plus, the Patient Portal, offers convenient and secure access to your personal health record and a way to message your physician’s office. As the patient, you are in control of your Portal record: we will not activate your personal account unless you authorize us to do so.

Because personal identifying information and other information about your health and medical history is available via the Portal, it is very important that you keep your password private. Do not share your password with anyone or write it in a place easily accessible to others.

If you choose not to execute this User Electronic Mail Authorization Form, you will not be able to access the Portal. If you choose to submit this form, you understand you are consenting for us to email you a unique link that you will use to create a password in order to access the Portal. Please look for an email from My Care Plus three to five business days after submitting this form. For your protection, the link is designed to expire quickly if not used. If you should change your email address, please contact your physician’s office in order to provide your new email contact information so that you will continue to receive updates and other pertinent information about the Portal or your medical record. Please choose an email address that will not be subject to access by anyone you do not trust.

If you wish to discontinue utilizing the Portal, please contact your physician’s office.
I hereby opt into My Care Plus, the Patient Portal:*

YesNo
If you selected yes, please provide a secure email address below:
example@example.com
Patient Signature*

Clear
Patient's Designee's Signature

Clear
Patient's Designee's Name:

CONSENT FOR RELEASE OF MEDICAL RECORDS
I hereby give my consent to release any or all requested records as listed below to Hematology and Oncology Associates of Northern California. Please select all the boxes.*

HISTORY AND PHYSICALPATHOLOGY REPORTSRADIOLOGY REPORTSLABORATORY RESULTSOPERATIVE REPORTSDISCHARGE SUMMARY / HOSPITAL REPORTSPHYSICIAN NOTESOTHER
Signature*

Clear
Responsible Party Signature:

Clear
Relationship:

RELEASE OF INFORMATION

Please list any family members or friends whom you would like for Hematology and Oncology Associates of Northern California to release/discuss your medical information.

	Name:	Contact info:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Patient Signature:*

Clear

ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITIES
Patient Phone Number:*

Area CodePhone Number
Cell Number:

Area CodePhone Number
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SS#:
Marital Status:

MarriedSingleDivorcedWidowed
Email:
example@example.com
Preferred Contact Method:

CellHomeWorkEmailMail
Preferred Language:
Employer Name:
Employer Phone Number:
Employer Address:
Occupation:
Responsible Party Name:
Phone Number:
Relationship:
Emergency Contact Name:
Phone Number:
Relationship:
Primary Ins:*
Telephone:
Insured Name:
Policy #:*
DOB:
Group #:
Secondary Ins:
Telephone:
Insured Name:
Policy #:
Group #:
I hereby give lifetime authorization for payment of insurance benefits to be made directly to Hematology and Oncology Associates of Northern California, and any assisting physicians, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance, in the event of default, I agree to pay all costs or collections, and reasonable attoney's fees.

I hereby authorize this healthcare provider to release all information neessary to secure the payment of benefits.

I further agree that a photocopy of this agreement shall be as valid as the original.

This agreement/consent will remain in effect unless revoked by me in writing.

I have read and received a copy of the above statements and accept the terms. A duplicate of the statement is considered the same as original.
Patient Signature:*

Clear
Responsible Party Signature:

Clear
Relationship:

NOTICE TO PATIENT ABOUT CMS OPEN PAYMENTS DATABASE
The CMS Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payments and other payments of value worth over ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hosptials be made available to the public.

I have read and understand the above statement and accept the terms. A Duplicate of the statement is considered the same as the original.
Patient Signature:*

Clear
Responsible Party Signature:

Clear

FINANICAL AGREEMENT
Hematology and Oncology Associates of Northern California is committed to providing the highest level of professional Medical care. For every commitment there is an obligation to provide quality care and service. Conversely, it is the Patients responsibility to meet their financial obligation.

This financial agreement should answer questions regarding patient and insurance responsibility for services rendered. Please read this agreement, ask us any questions you may have, and sign in the space provided. You will be given a copy of this agreement for your records.

I have received this financial policy, and understand that regardless of any insurance coverage I may have, I am responsible for payment of my account. I understand that delinquent accounts may be referred to a collection service. I also acknowledge that I have received a copy of this financial agreement for my records.

Insurance

Your insurance coverage is a contract between you and the insurance company, and it is your responsibility to know your insurance benefits. As a courtesy, we will bill both your primary and secondary insurance companies. We will submit your claims and assist you in any way we reasonably can to help get your claims processed. In order to do this, we must receive all the information necessary to bill. If the information is not supplied, you will be billed, and payment in full will be your responsibility and will be expected within 30 days of receipt of statement.

Medicare

We participate in Medicare. You are responsible for your co-insurance, any deductibles that have not yet been met, and services that are identified as patient responsibility on your Medicare Explanation of Benefits. We strive to inform our Medicare patients of services that will not be covered. We may ask you to sign an Advanced Beneficiary Notice, which lists out fee and notifies you of your financial responsibility for certain medical services.

Managed Care

Many patients are enrolled in Managed HealthCare. In order for us to obtain referrals and/or pre-authorizations for procedures, it is important that we have your current information. Depending on individual policies, your procedure may not be a covered benefit. It is your responsibility to check for optimal covered and policy limitations, and to obtain referrals as required by your insurance company. Please contact your insurance company with questions regarding your coverage.

Patient Responsibility for Payment

You are responsible for payments of any co-payment, co-insurance, deductible or service not covered by your insurance, handing, collection or attorney fees. If you do not have insurance, you are responsible for payment of all services. Co-payments are due at the time of your service. Patient due balances noted on your monthly statement are due within 30 days of receipt. We will bill appropriate insurance if all required information is provided.

Deposits

New patients without insurance, or if insurance co-payment and coverage cannot be verified, are required to a deposit on or before the first date of service. If insurance payments results in a credit balance, it will be refunded to you within 30 days.

Payment Options

We understand that financial circumstances vary from patient to patient. If you are unable to pay your patient due balance in full, you must call our business office at 916-250-0166 to make payment arrangements. We offer uninsured patients a 10% discount for payment of office visit by cash, check, or credit card received on the date of service. Discount does not apply to lab or supply charges. Accounts with a patient due balance outstanding over 30 days will be charged a finance charge.

Non-Payment

Failure to pay will result in your account being referred to a collection agency, which may affect your credit. You must contact out collection analyst to discuss payment arrangements. If it becomes necessary to send my account to a collection service, I agree to pay for all costs and expenses, including reasonable attorney fees.
Patient Signature:*

Clear
Signature

Clear
Should be Empty:

CONSENT FORMS

SUMMARY NOTICE OF HIPAA PRIVACY PRACTICES

CONSENT FOR ELECTRONIC MEDICATION HISTORY ACCESS

Consent for HOAONC to Fill Prescription(s)

CONSENT FOR PATIENT PHOTOGRAPHY

PATIENT PORTAL: MY CARE PLUS

User Electronic Mail Authorization Form

CONSENT FOR RELEASE OF MEDICAL RECORDS

RELEASE OF INFORMATION

ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITIES

NOTICE TO PATIENT ABOUT CMS OPEN PAYMENTS DATABASE

FINANICAL AGREEMENT