Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form, I understand that:
This Authorization remains valid until patient is no longer under care with Abundant Health Physical Medicine of Davenport, IA, unless effectively revoked in writing by the individual before that event.
All professional services rendered are charged to the patient and are due at the time of service unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments.
Assignment of Benefits
I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carriers), including Medicare, private insurance, and any other health/medical plan, to issue payment check(s) directly to Abundant Health Physical Medicine of Davenport, IA for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.
Authorization to Release Information
I hereby authorize Abundant Health Physical Medicine of Davenport, IA to:
This order will remain in effect until revoked by me in writing. I have requested medical services from Abundant Health Physical Medicine of Davenport, IA on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.
I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.
By signing this form, I authorize Abundant Health Physical Medicine of Davenport, IA to release my confidential health information, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to designated physician(s)/person(s)/facility/entity and/or those directly associated with the medical care I will receive at this facility.