1. Authorization for Medical and/or Diagnostic Treatment: I hereby consent and authorize my practitioner(s), their associates and assistants and Centerstone Health Services, its agents and employees to administer and perform such treatments, medical and surgical procedures, examinations, tests, including tests for communicable disease, which in the judgment of medical practitioner(s) may be considered necessary or advisable. If I should leave the Centerstone Health Clinic or refuse medical treatment against the medical advice of my practitioners(s), I hereby release said providers(s) and Centerstone Health Clinic for all liability related to my actions. I agree that I am under the control of my attending health care practitioners and the facility is not liable for any act or omission of mine in following the instruction of said health care practitioners.
2. Release of Information/Payment Request for Medicare/Medicaid Claims: I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I request that payment of authorized Medicare benefits be made on my behalf for any service furnished by or in Centerstone Health Services, including physician/practitioner services, or by any physicians/practitioners employed by Centerstone Health Services. I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or benefits for related services. I permit a copy of this authorization to be used in place of the original. I understand and agree that any health information (data) generated by Centerstone Health Services may be exchanged with outside healthcare entities in order to facilitate continuity of care on my behalf.
3. Assignment of Insurance Benefits Non-Medicare: I hereby assign to Centerstone Health Services all insurance benefits (including any major medical payments) due to me as a result of outpatient, hospitalization, or emergency treatment of the patient named below and pursuant to any insurance contract I have which provides coverage for such hospitalization or treatment. I authorize Centerstone Health Services to release any medical or financial information for the purpose of obtaining payment of insurance benefits for this and/or a related claim. I authorize and direct any such insurance company to make payments directly to Centerstone Health Services. I permit a copy of this authorization to be used in place of the original. Note: For work related injured and illnesses, protected health information is released to the employer.
4. Independent Contractors: I understand that some health care practitioners furnishing services to me are independent contractors and are not employees or agents of Centerstone Health Services. I may receive a bill from these contractors and understand I have the option to communicate with Centerstone Health Services employees to explore resources available to me for financial assistance.
5. Your participation in telehealth services is voluntary. If you decide that you do not wish to participate in telehealth services you may discontinue them at any time and face to face services will be arranged if available for you. By signing below, I understand that all information about me will remain confidential and will be used only for treatment purposes.
I, THE UNDERSIGNED, CERTIFY THAT I HAVE READ THE FOREGOING, AND AM THE PATIENT, OR AM DULY AUTHORIZED AS PATIENT’S GENERAL AGENT TO EXECUTE THE ABVOVE AND I ACCEPT ITS TERMS.