Five Rivers Health Centers General Consent Agreement

CONSENT TO TREATMENT: I consent to, and authorize Five Rivers Health Centers to provide, all necessary care, including examinations, testing and treatment. I also consent to such tests and procedures necessary for infection control.

TREATING PHYSICIANS: I understand that the physicians who render professional services to me at Five Rivers Health Centers may be independent practitioners and not employees or agents of the Centers. I agree that Five Rivers Health Centers is not responsible for the acts or omissions of physicians that are not directed or controlled by Five Rivers Health Centers and that these physicians’ charges will be billed separately in addition to the centers’ charges. I assign to these physicians any insurance and other benefits to which I am entitled for the services provided by them

SUPPORTIVE SERVICES: I understand that supportive services such as behavioral health counseling, substance abuse screening and counseling, and/or case management services may be recommended to me by my physician based upon my presenting needs. I also understand that these services will be billed separately in addition to the physician and center charges. I assign to these behavioral health providers any insurance and other benefits to which I am entitled for the services provided by them.

I acknowledge that I received Five Rivers Health Centers Notice of Privacy practices which sets forth the ways in which my personal health information may be used or disclosed by Five Rivers Health Centers and outlines my rights with respect to such information.

FINANCIAL AGREEMENT AND ASSIGNMENT: I agree to pay Five Rivers Health Centers, as bills are presented and at Five Rivers Health Centers’ prevailing rates, all charges which are not satisfied by insurance or other third-party payer. I assign to Five Rivers Health Centers all insurance and other benefits to which I am entitled for the services provided by Five Rivers Health Centers. I direct that all such benefits be paid directly to Five Rivers Health Centers. Should my account become delinquent, I agree to pay interest at the legal rate, from date of discharge. I authorize Five Rivers Health Centers to obtain a copy of my credit report and other necessary financial information. I agree that, to the extent permitted by applicable law; Five Rivers Health Centers is fully subrogated to all of my rights to receive compensation or benefits from any person or governmental entity for the centers’ goods and services provided to me. I understand that, pursuant to section 3727.42 of the Ohio Revised Code, I am entitled to a list of Five Rivers Health Centers’ usual and customary charges for selected services. I may obtain that list upon request

COOPERATION WITH BILLING: I understand that although Five Rivers Health Centers may assist me in doing so, I am solely responsible for compliance with the provisions of my insurance policy, including verifying coverage and obtaining any required pre-admission certification. I agree to cooperate fully with Five Rivers Health Centers in billing my insurance and any other third-party payer, including, but not limited to, promptly responding to requests for information from Five Rivers Health Centers, or any insurer or other third-party payer. I also understand that in order to receive any financial assistance in paying my bill, I must promptly and truthfully complete all required applications, provide requested supporting documentation and fulfill all other requirements of the assistance program. I agree that my failure to cooperate in these matters may result in the denial of benefits or assistance. If any insurer or other third-party payer denies payment of Five Rivers Health Centers claim; I will promptly pursue all appeals processes available to me. I also authorize Five Rivers Health Centers to appeal such denial on my behalf. I agree, in order for Five Rivers Health Centers to service my account or to collect any amounts I may owe, Five Rivers Health Centers may contact me by telephone at any telephone number associated with my account, including wireless telephone numbers, and may also contact me by sending text messages or e-mails, using any e-mail address I provide to use which could result in charges to me. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

MEDICARE PATIENTS: I certify that any information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers, agents or attorneys, any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf to the provider.

PERSONAL PROPERTY: I agree that Five Rivers Health Centers is not responsible for the loss of money or valuables I bring with me.

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CONSENT TO TREATMENT: I consent to, and authorize Five Rivers Health Centers to provide, all necessary care, including examinations, testing and treatment. I also consent to such tests and procedures necessary for infection control.

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TREATING PHYSICIANS: I understand that the physicians who render professional services to me at Five Rivers Health Centers may be independent practitioners and not employees or agents of the Centers. I agree that Five Rivers Health Centers is not responsible for the acts or omissions of physicians that are not directed or controlled by Five Rivers Health Centers and that these physicians’ charges will be billed separately in addition to the centers’ charges. I assign to these physicians any insurance and other benefits to which I am entitled for the services provided by them.

Late Cancellation of Appointments
You must call to cancel a scheduled appointment prior to the appointment to avoid being considered a “no show”.

No Show’s
You can be dismissed from all FRHC sites if you do not show to three (3) scheduled appointments. Dismissed patients may be accepted back as patients only after they are seen for 3 walk-in/work-in visits.

Insurance/ Financial Policies
Co-Payment is due at the time of service.

Late for appointment
If you are more than 15 minutes late for your scheduled appointment, you may not be seen and will possibly need to reschedule.

Forms
FRHC providers will complete forms for patients within 7-10 days of receipt depending on their availability

Behavior/ Conduct
Using foul language, verbal abuse or threatening behaviors towards staff, providers and or patients could be grounds for dismissal from all FRHC sites.

Records
There will be a charge for copies of medical records obtained for your self No charge will be incurred when copies of records are requested by and sent directly to another provider.

Photographs/ Video/ Voice Recording
The taking of photographs/ video recordings or voice recordings (without permission) is strictly prohibited by any patient, family member or visitor at any of the Five Rivers Health Centers sites.

Firearms/ Weapons
Firearms and other weapons are not permitted on FRHC property.

 

 

Non- Discrimination of Staff by Age, Gender, Race, Religion, Sexual Orientation for Patient Safety
FRHC will make every effort to accommodate the patient’s cultural and religious needs and requests as long as patient safety and quality of care provided are not compromised.

We ask the following of our patients as a Code of Conduct.
No profanity in the office. Please refrain from cell phone conversations, while at registration and patient care areas. Please inform friends and family members to adhere to the code of conduct as well.

Please choose from Option 1 OR Option 2
The following individuals have permission to interact with Five Rivers Health Centers on my behalf, (check each box that applies).

I understand that this authorization shall remain in effect for one year from the date of my signature below unless I specify an earlier expiration date in this space

I understand also, that except to the extent that action has been taken based on my authorization, I may withdraw this authorization at any time by written notification to the parties involved (see Notice of Privacy Practices).

• I understand that as an integrated Health Care Facility Five Rivers Health Centers offers a variety of services to meet the needs of its patients.  These Services include Medical, Dental, Vision, Behavioral Health, Pharmacy, Dietician, Telehealth, Podiatry, Acupuncture, as well as several specialty services.

•  I acknowledge that these various services will be billed separately to my insurance, if applicable, and I will be fully responsible for any copay, coinsurance, and deductible amounts.

•  If I am a self-pay patient, I acknowledge that I will be responsible for any incurred charges in full.