HIPAA CONSENT & BILLING RELEASE
CONSENT FOR TREATMENT: By signing this form, I consent to and authorize my health care provider to assess and treat me. I understand that my provider is available to explain the purpose of the services and that I have the right to refuse the recommended services. Services may include face-to-face or via remote support.
CONSENT TO SHARE INFORMATION WITHIN ANISHINAABE ENDAAD: I understand that I am seeing a health care provider within Anishinaabe Endaad, and that property management and services are linked by a computer database. This allows them to share confidential information within Anishinaabe Endaad to provide high-quality
RELEASE OF MEDICAL RECORDS FOR MY MEDICAL CARE OR AS REQUIRED BY LAW: I agree to release my medical information to be viewed within the agency to coordinate my care. This includes release to any of the Anishinaabe Endaad Business Associate for purposes of my services and for business operations. I also agree that Anishinaabe Endaad can release my medical records to accrediting or regulatory agencies if those agencies request my records as allowed by the law.
INSURANCE / MEDICAID - PAYMENT OF ANISHINAABE ENDAAD BILLS: I consent to the disclosure of my protected health information for the purpose of payment, treatment, and program operations. I request that payment of authorized benefits be made to the Anishinaabe Endaad LLC on my behalf for any services furnished to me by Anishinaabe Endaad. I assign the benefits payable for services to the organization furnishing the services. In consideration of services, I agree to pay Anishinaabe Endaad for all charges not covered by any third-party payer.
OTHER SERVICES: Anishinaabe Endaad may use other companies to help in my assessment and services. If another company performs a service, they will bill my insurance. Anishinaabe Endaad cannot answer questions about bills received from other companies.
PATIENT'S RIGHT TO PRIVACY PRACTICES / HIPAA: I acknowledge that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow-up among providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers, a list is available upon request. If I would like a copy of Anishinaabe Endaad's privacy form, I will ask for one. I understand that my health records will not be used for research without my permission as described in the Privacy Notice. However, for the purpose of improving Anishinaabe Endaad's services and program planning, my health data may be used in aggregate by the program for future grants.