PATIENT DEMOGRAPHIC INFORMATION
Name and contact information of any other individuals allowed to obtain details in patient care information
Consent for Service, Authorization of Payment, Authorization for Release,
Consent for Medications
1. I request for medical services of SHAE Medical, PLLC and request that payment authorized insurance (including Medicare) benefits be made on my behalf to SHAE Medical, PLLC for medical services including but not limited to:
a. Chronic care management
b. Integration of behavioral health integration care management services
c. Tele-health visits and all communication-based technology service
2. I authorize the release of my medical records to SHAE Medical, PLLC upon its request for dates of treatment going back 2 years from the date below, including all discharge summaries, progress notes, consult notes, laboratory testing, and imaging studies.
3. I authorize SHAE Medical, PLLC to release to my insurance company and/or to the Centers for Medicare and Medicaid Services and its agents and information needed to determine these benefits or the benefits payable to/for related services, including but not exclusive of a clinical diagnosis, treatment plans and summaries and/or copies of the entire record. I also agree that SHAE Medical, PLLC can provide the requested information to my insurance carrier.
4. I acknowledge that I am financially responsible for all charges for services provided to me, including but not limited to any portions of my medical care that my insurance company assigns to me for in-person and non-face-to-face services provided. Once insurance is filed, I authorize the use of my credit or debit card for payment of these balances owed. I understand that my credit card will be securely saved on file for future transactions on my account until expiration of provided card. My responsible party/financial agent can be informed that I am receiving services for billing purposes unless I request otherwise.
5. I understand my records will be kept on file at the facility where services are provided and securely in an Electronic Medical Record.
6. I authorize SHAE Medical, PLLC to seek emergency medical care on my behalf if deemed necessary.
7. I understand there are risks, side effects, benefits, and possible drug-drug interactions of medication(s) prescribed. I and/or my legal guardian, understand there are risks, where applicable, during pregnancy, in the elderly, and other pertinent risk factors such as FDA black box warnings. I and/or my legal guardian are indicating awareness and have given informed consent for medication(s) and or therapies to be prescribed for their intended use as part of the treatment process.
8. I acknowledge review of the SHAE Medical, PLLC Notice of Privacy Practices and Client Rights and Grievance Policies. A copy is available on our website at shaemedical.com/npp . If requested, a copy will be provided to me.
9. I acknowledge review of the SHAE Medical HIPPA Policy which is located on the website at shaemedical.com/hippa. If requested, a copy will be provided to me.
10. I acknowledge that I have the right to refuse treatment as described in the statute without threat or termination of services except as outlined in G.S. 122-C-57(d); 10A NCAC 27D . 0303 (c). This consent for treatment may be withdrawn at any time.
Advanced Beneficiary Notice—NOTE: please check ACCEPT or DECLINE; for more information, check out shaemedical.com/abn