1. I consent to exam and treatment as necessary, including acquisition of medical, behavioral health and pharmaceutical history. I hereby authorize Centerstone Health Services (CHS) to release any information regarding services rendered by Centerstone Health Services to my insurance company and in the case of Medicare and the Health Care Financing and its agents; and allow a photocopy of my signature to be used to file insurance, including Medicare, when applicable. I request that payment, including Medicare- authorized benefits be made either to me or on my behalf to Centerstone Health Services. I authorize and direct my insurer to issue payment for authorized benefits due me for services rendered by Centerstone Health Services to be made directly to Centerstone Health Services. Regardless of my health insurance benefits, if any, I understand that I am financially responsible for the fees for services and any cost incurred.
2. My participation in telehealth services is voluntary. I verify that telehealth services have been explained to me and I voluntarily agree to participate. I understand that all information about me will remain confidential and will be used only for treatment purposes.
3. With my consent, Centerstone Health Services (CHS) may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). The CHS Notice of Privacy Practices (NPP) lists a complete description of such uses and disclosures and I have the right to review and receive if requested the NPP prior to signing this consent. CHS reserves the right to revise its Notice of Privacy Practices at any time.
4. With my consent, CHS may call my home, cell or designated location and leave a message on voicemail or in person about any items that assists CHS in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care, including lab results among all others. With my consent, CHS may mail to my home or other designated location any items that assists CHS in carrying out TPO, such as appointments, reminder cards and statements. With my consent, CHS may send SMS and email messages to my mobile telephone or email address that I provide about any items that assists CHS in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care, including lab results among all others.
5. Authorization is hereby granted to receive and to release all medical record information of treatment for physical and/or emotional illness, including pharmacy, treatment of drug and alcohol abuse to another health care provider, including faxing this information upon my transfer for further care.
6. I have the right to request that CHS restrict how it uses or discloses my PHI to carry out TPO. However, CHS is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
I, THE UNDERSIGNED, CERTIFY THAT I HAVE READ THE FOREGOING, AND AM THE PATIENT, OR AM DULY AUTHORIZED AS PATIENT’S AGENT TO EXECUTE THE ABOVE AND I ACCEPT ITS TERMS.