CONSENT FOR CARE AND TREATMENT
Authorization to Release Information and Assignment of Benefits:
I give consent, by signing below, to Alaska Bleeding Disorder Clinics (AKBDC) to release the personal data as required in the course of examinations and treatment for purposes of billing and filing insurance coverage or other financial claims related to the care provided. I consent to assign all payments for services to AKBDC or persons billing on their behalf, for care performed or services rendered by the providers where within to the patient named below. I also understand that Alaska State Law requires AKBDC to report all vaccine records to the AK State Registry (VacTrack).
Assumption of Financial Responsibility:
I, by signing below, assume financial responsibility for payment of fees stemming from care rendered or services provided by AKBDC to the patient named below. Insurance or other coverage may pay for part of these charges, and I assume responsibility for any unpaid portion.I understand that Pricing information and description of services may be requested. In accordance with Anchorage Municipal Code 16.130.010 (A Healthcare Transparency Policy) – AKBDC will provide you with an estimate of the anticipated charges of your care, upon request. Questions welcome at any time.If I fail to pay outstanding balances or fail to comply with an arranged payment plan, I accept all charges associated with collections from AKBDC.
HIPPA Notice of Privacy Practices:
I understand that AKBDC provides the opportunity to view the HIPAA Privacy Practices and the rights I have regarding health information anytime requested, Questions are welcome at any time as well.
I understand that AKBDC complies with applicable Federal civil rights laws and does not discriminate based on race, color, national origin, age, disability, or sex. Language assistance services, free of charge, are available to you. Call 907-917-9235 (TTY Not Available by Phone, but accommodations can be made).
Consent for Care:
You have the right to be informed about your condition and the recommended surgical, medical, diagnostic procedure to be used so that you may make the decision whether to accept any suggested treatment or procedure after knowing the risks and hazards involved.You have the right, at any time, to decline or discontinue any or all services. You have the right to discuss the treatment plan and any orders with the provider – the purpose, potential risks, benefits, other questions, any concerns,By signing below, you are indicating that you consent for care by any Physician, Nurse Practitioner, Physician Assistant, nurse, or designated individual associated with AKBDC. The ability to discuss patient information is kept to strict adherence to HIPAA standards and will be limited as necessary to adhere to those standards.By initialing, I also give consent for demographic information to be shared with Alaska Hemophilia Association.This consent will remain fully effective for 1 year or until it is revoked in writing. If additional testing, invasive or interventional procedures are recommended, you will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).I certify that I have read and fully understand the above statements and hereby consent fully and voluntarily to its contents.
I agree to the HIPAA Privacy Statement.
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