HIPAA Consent Form

I understand that under the Health Portability and Accountability Act 1996 (HIPAA) I have certain rights to privacy regarding my health information.  I also understand that Cedar Grove Foot & Ankle Specialists originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, test results, diagnoses, treatments and any plans for future care and treatment at Cedar Grove Foot & Ankle Specialists.  I understand that this information can be used as:

• A basis for planning my care and treatment and followup among multiple healthcare providers who may be involved in that treatment directly or indirectly.
• A means of communication amoung the many healthy professionals who contribute to my care
• A means by which a 3rd party can verify that services billed were actually provided and obtain payment from 3rd party payers
• A tool for routine healthcare operations such as assessing quality and receiving the competence of healthcare professionals

Notice of Privacy Practices

Acknowledgement of Receipt

I acknowledge that I was provided an opportunity to read (if I chose to), a copy of the notice of Privacy Practices and understood the notice.

Financial Responsibility / Insurance Benefits / Notice of Collection Action

I understand that I am responsible for knowing the benefits of my insurance plan.  In doing so, it is my responsibility to verify proof of insurance by ensuring that the office has the most current/valid insurance on file.  I understand that all co-payments are due at the time of service and I am also responsible to pay other amounts due; these amounts may include deductibles, coinsurances, charges denied by my insurance as not covered or not medically necessary and/or any fees incurred should my account require collection action (late fees, collection agency, court or attorney fees).  Also, I understand that on occasion, the office may contact my insurance to obtain benefit information as a courtesy to me, however the information obtained from the insurance company is not a guarantee of payment, which may still result in my responsibility.