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, Integration of behavioral health integration care management services, Tele-health visits and all communication-based technology services
2. If deemed necessary for treatment, I authorize the release of my previous medical records to SHAE Medical, PLLC
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 services provided to me, including portions of my medical care that my insurance company assigns to me.
5. I understand my records will be kept on file at the facility where services are provided and securely in an Electronic Record.
6. I authorize SHAE Medical, PLLC to seek emergency medical care on my behalf if deemed necessary.
7. I have received SHAE Medical, PLLC Notice of Privacy Practices and Client Rights and Grievance Policies. A copy is available on our website at shaemedical.com/npp
8. I have read and agree to the complete HIPPA Form on the SHAE Medical, PLLC website at shaemedical.com/hippa
9. 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 This consent for treatment may be withdrawn at any time.