I authorize the release of any information concerning my health care advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor I understand that I am responsible for any amount not covered by my insurance I request that payment of authorized Medicare benefits be made to my physician.
Unfortunately, too many of our patients are missing appointments repeatedly. When this occurs, it leaves fewer appointments available for patients who need care. We realize that the occassional missed appointment may be unavoidable, but this should be rare.
Any appointment missed, or cancelled without 24 hours notification will be considered a "No Show". The charge per "No Show" is $25.00. After a total of three "No Show" appointments within a short interval of time, the patient will be regretfully discharged from our practice, and from our care. No further appointments will be scheduled, due to the unwillingness to follow our physician's plan of health care.
Thank you for your understanding and cooperation.
I have read and understand the above policy.
My signature acknowledges my receipt of the Notice of Privacy Practices from Agape Primary Care.
Agape Primary Care is authorized to release protected health information concerning the above named patient to the entities listed below. The purpose is to inform the patient of designee of health matters, as per the patient instructions.
Rights of Patient: I understand that I have the right to revoke the authorization at any time and that I have the right to inspect a copy of the protected health information to be disclosed as described in the Notice of Privacy Practices previously provided to me. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this information may be subject to re-disclosure by the recipient and may no longer be protected by federal state law.
I understand that I have the right to refuse to sign this authorization and that my treatment will be conditioned or signing. This authorization shall be in effect until revoked by patient.
I have been made aware and understand that the medical practices and office may use an electronic prescription system which allows prescriptions and related information to be electronically sent between my providers and my pharmacy. I have been informed and understand that my providers using the electronic prescribing system will be able to see information about medications I am already taking, including those prescribed by other providers. I give my consent to my providers to see this protected health information.
Your answers on this form will help your health care provider better understand your medical concerns and conditions. If you are uncomfortable with any question, do not answer it. If you cannot remember specific details, please approximate them. Add any notes you think are important. ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.
Are you interested in having your prescriptions mailed to your home?
Main Street Physicians partners with SC Home Rx to provide you with a simple & excellent pharmacy experience. SC Home Rx can deliver your prescriptions every month at the same time and you never have to wait in line again at a traditional pharmacy. Talk to your provider today about setting up SC Home Rx as your preferred pharmacy.
Fill out information below if you answered "Yes".
Otherwise, skip to "Past Medical History".
I hereby authorize Main Street Physicians/SC House Calls to use or disclose my protected health information as described below. I understand that the information I authorize a person/facility to recieve my be re-disclosed and no longer protected by state and federal regulations.
Name of Person/Facility Authorized to recieve the information:
Main Street Physicians/SC House Calls
I understand that in the event I was treated for drug or alcohol abuse, psychiatric condition, and/or communicable diseases including HIV/AIDS this information will be included as part of my medical record to the above-named person/facility.
LTC Health Solutions may not condition treatment, payment, enrollment or eligibility for benefits on signing this authorization.
This authorization is subject to cancellation/revocation at any time, by the patient or legally qualified representative, provided that the cancellation is made in writing except to the extent that:
This authorization will expire in 90 days unless otherwise stated.