HIPPA Consent and Release: 

I authorize Immaculate Heart of Mary Family Health Center to release the protected health information of my child to the following adults who may be involed in my child's medical care. 

The name(s) listed below are adult friends or family members whom I grant permission for Immaculate Heart of Mary Family Health Center's employees and/or medical providers, to discuss my child's medical care, and make medical decisions for your child if needed.

Primary Insurance Info: 

Secondary Insurance Info: 

Health-sharing ministry financial agreement:

Terms and Conditions:

 
As a member of a health sharing organization, health share ministry, or health share/cost sharing arrangement I understand and agree to the following policies of Immaculate Heart of Mary Family Health Center (2175 N. Alma School Rd. Suite 109, Chandler AZ 85224):
 
1.     I understand and agree that I will pay an upfront cost of $150 prior to my (or my dependents) appointment.
 
2.     I understand and agree that I will pay for any additional medications, procedures, tests, labs, or immunizations at the time of the appointment.
 
3.     Once my health sharing organization has processed the claim related to my appointment, a refund will be provided to me if the upfront amount I paid at the time of the appointment exceeds the negotiated rates with my health sharing organization.
 
4.     If the upfront amount I paid at the time of the appointment is less than the negotiated rates, I will be billed for the difference.
 
5.     If I do not respond to the bill/invoice within 30 days the card on file will be charged for the total amount due.
 
6.     This agreement will remain in effect indefinity or until an updated policy statement is provided.
 
7.     This agreement applies to myself, and all of my dependents who are currently, or future patients of Immaculate Heart of Mary Family Health Center.

 Plan 1: Pay per visit

- with this plan you pay a low cost everytime you visit the clinic, and a percentage of additional costs such as vaccines, medicines, and additional procedures. 

Plan 2: Unlimited visits

- with this plan you may visit the clinic as many times as you wish and only pay a low montly membershp fee. 

Sliding Fee Scale Agreement: 

1.    Patient Agreement: This is an agreement between Immaculate Heart of Mary Family Health Center (2175 N. Alma School Rd. Suite 109 Chandler, AZ 85224), and the patient listed above.
 
I understand and acknowledge that I am voluntarily agreeing to enroll into a sliding fee scale payment arrangement with Immaculate Heart of Mary Family Health Center. This agreement is non-transferable.
Final enrollment into the program is at the discretion of the executive director.
 
2.    Services: I acknowledge and understand that this charity program only applies to services rendered by Immaculate Heart of Mary Family Health Center, and its staff.
 
I am responsible for any charges incurred for health care services performed outside of the prevue of Immaculate Heart of Mary Family Health Center. This includes, but is not limited to, ER visits, inpatient hospitalizations, specialist care, imaging and laboratory services, pharmaceuticals, and any other health care services not directly offered by Immaculate Heart of Mary Family Health Center.
 
3.    Immaculate Heart of Mary Family Health Center is not insurance.
This agreement does not provide comprehensive health insurance coverage, nor is it a contract of insurance. It provides only the health care services specifically provided by Immaculate Heart of Mary Family Health Center.

4.    Termination of agreement.
I acknowledge and understand that both Immaculate Heart of Mary Family Health Center and I have the absolute and unconditional right to terminate this agreement, without the showing of any cause for termination. I may terminate my agreement with Immaculate Heart of Mary Family Health Center at any time and for any reason by providing written notice to Immaculate Heart of Mary Family Health Center.
Immaculate Heart of Mary Family Health Center will not terminate this agreement solely based on health status. Immaculate Heart of Mary Family Health Center will assist transferring records and care to the new primary care physician designated by the patient. Any payments outstanding through the date of termination of the agreement are the responsibility of the patient

Immaculate Heart of Mary Family Health Center

Unlimited montly memberships - Patient Agreement: 

1.    Patient Agreement: This is an agreement between Immaculate Heart of Mary Family Health Center (2175 N. Alma School Rd. Suite 109 Chandler, AZ 85224), and the patient listed above.
 
I understand and acknowledge that I am voluntarily agreeing to purchase a direct primary care membership with Immaculate Heart of Mary Family Health Center. This monthly membership agreement is non-transferable.

The effective date of the membership is the date this agreement is signed.
 
2.    Membership: I am agreeing to enroll into the membership direct primary care program.

After paying my nonrefundable enrollment fee listed below, I acknowledge and agree to pay my monthly membership fee on or before the due date. Monthly fees will begin on the date of the first visit, and will continue monthly thereafter. Monthly fees will be automatically billed to the credit or debit card you provide to us, or by ACH withdrawal. This payment will cover the following month’s services fee.
Any additional labs, medications or diagnostic testing will be charged at the time of service and payment in full is expected at that time. In the event I am unable to pay my fee(s) on time, I understand I will be charged a $30 late fee and that this agreement may be terminated.

3.    Services: I acknowledge and understand that this membership only applies to services rendered by Immaculate Heart of Mary Family Health Center, and its staff.
 
I am responsible for any charges incurred for health care services performed outside of the prevue of Immaculate Heart of Mary Family Health Center. This includes, but is not limited to, ER visits, inpatient hospitalizations, specialist care, imaging and laboratory services, pharmaceuticals, and any other health care services not directly offered by Immaculate Heart of Mary Family Health Center.
 
 
4.    Immaculate Heart of Mary Family Health Center is not insurance.
 
State of Arizona required statement:
 
NOTICE: THE ORGANIZATION FACILITATING THE DIRECT PRIMARY CARE AGREEMENT IS NOT AN INSURANCE COMPANY AND THE DIRECT PRIMARY CARE COMPANY GUIDELINES AND AGREEMENT ARE NOT AN INSURANCE POLICY. PARTICIPATION IN THE DIRECT PRIMARY CARE AGREEMENT OR A SUBSCRIPTION TO ANY OF ITS DOCUMENTS SHOULD NOT BE CONSIDERED TO BE A HEALTH INSURANCE POLICY. REGARDLESS OF WHETHER YOU RECEIVE TREATMENT FOR HEALTH CARE ISSUES THROUGH THE DIRECT PRIMARY CARE AGREEMENT, YOU ARE ALWAYS PERSONALLY RESPONSIBLE FOR PAYING ANY ADDITIONAL HEALTH CARE EXPENSES YOU MAY INCUR. IF YOU HAVE HEALTH INSURANCE, IT MAY INCLUDE, AT NO ADDITIONAL CHARGE, SOME OF THE PREVENTIVE SERVICES THAT ARE ALSO AVAILABLE UNDER THIS DIRECT PRIMARY CARE AGREEMENT. THE PRIMARY CARE PROVIDER MAY NOT BILL YOUR HEALTH INSURANCE FOR PRIMARY CARE SERVICES PROVIDED UNDER THIS DIRECT PRIMARY CARE AGREEMENT.
 
This agreement does not provide comprehensive health insurance coverage, nor is it a contract of insurance. It provides only the health care services specifically provided by Immaculate Heart of Mary Family Health Center. Immaculate Heart of Mary Family Health Center will not bill insurance carriers for any services. If patients wish to seek reimbursement, they will be provided with office notes and a superbill (if appropriate) which patients can submit in an attempt to receive reimbursement from insurance companies or others. I understand that Immaculate Heart of Mary Family Health Center will not provide administrative support for these matters.
I understand that the Internal Revenue Service does not consider primary care monthly services fees eligible for payment with HSA, HRA, or FSA accounts.
It is highly recommended to maintain health insurance for unpredictable and catastrophic expenses.

5.    Termination of agreement.
I acknowledge and understand that both Immaculate Heart of Mary Family Health Center and I have the absolute and unconditional right to terminate this agreement, without the showing of any cause for termination. I may terminate my agreement with Immaculate Heart of Mary Family Health Center at any time and for any reason by providing written notice to Immaculate Heart of Mary Family Health Center, and the agreement will terminate at the end of the current payment month.
Immaculate Heart of Mary Family Health Center will not terminate this agreement solely based on health status. Immaculate Heart of Mary Family Health Center will assist transferring records and care to the new primary care physician designated by the patient. Any payments outstanding through the date of termination of the agreement are the responsibility of the patient

6.    Re-Enrollment
I acknowledge and understand that if I terminate my Immaculate Heart of Mary Family Health Centeragreement after receiving initial services, I may be allowed to reestablish my enrolled patient status only after payment of the rejoining fee of $100. I acknowledge and understand that Immaculate Heart of Mary Family Health Center is not obligated to allow me to reenroll if I have previously terminated my agreement.

Immaculate Heart of Mary Family Health Center

Direct Primary Care Patient Agreement: 

1.    Patient Agreement: This is an agreement between Immaculate Heart of Mary Family Health Center (2175 N. Alma School Rd. Suite 109 Chandler, AZ 85224), and the patient listed above.
 
I understand and acknowledge that I am voluntarily agreeing to purchase a direct primary care membership with Immaculate Heart of Mary Family Health Center. This monthly membership agreement is non-transferable.

The effective date of the membership is the date this agreement is signed.
 
2.    Membership: I am agreeing to enroll into the membership direct primary care program.

After paying my nonrefundable enrollment fee listed below, I acknowledge and agree to pay my monthly membership fee on or before the due date. Monthly fees will begin on the date of the first visit, and will continue monthly thereafter. Monthly fees will be automatically billed to the credit or debit card you provide to us, or by ACH withdrawal. This payment will cover the following month’s services fee.
Any additional labs, medications or diagnostic testing will be charged at the time of service and payment in full is expected at that time. In the event I am unable to pay my fee(s) on time, I understand I will be charged a $30 late fee and that this agreement may be terminated.

3.    Services: I acknowledge and understand that this membership only applies to services rendered by Immaculate Heart of Mary Family Health Center, and its staff.
 
I am responsible for any charges incurred for health care services performed outside of the prevue of Immaculate Heart of Mary Family Health Center. This includes, but is not limited to, ER visits, inpatient hospitalizations, specialist care, imaging and laboratory services, pharmaceuticals, and any other health care services not directly offered by Immaculate Heart of Mary Family Health Center.
 
 
4.    Immaculate Heart of Mary Family Health Center is not insurance.
 
State of Arizona required statement:
 
NOTICE: THE ORGANIZATION FACILITATING THE DIRECT PRIMARY CARE AGREEMENT IS NOT AN INSURANCE COMPANY AND THE DIRECT PRIMARY CARE COMPANY GUIDELINES AND AGREEMENT ARE NOT AN INSURANCE POLICY. PARTICIPATION IN THE DIRECT PRIMARY CARE AGREEMENT OR A SUBSCRIPTION TO ANY OF ITS DOCUMENTS SHOULD NOT BE CONSIDERED TO BE A HEALTH INSURANCE POLICY. REGARDLESS OF WHETHER YOU RECEIVE TREATMENT FOR HEALTH CARE ISSUES THROUGH THE DIRECT PRIMARY CARE AGREEMENT, YOU ARE ALWAYS PERSONALLY RESPONSIBLE FOR PAYING ANY ADDITIONAL HEALTH CARE EXPENSES YOU MAY INCUR. IF YOU HAVE HEALTH INSURANCE, IT MAY INCLUDE, AT NO ADDITIONAL CHARGE, SOME OF THE PREVENTIVE SERVICES THAT ARE ALSO AVAILABLE UNDER THIS DIRECT PRIMARY CARE AGREEMENT. THE PRIMARY CARE PROVIDER MAY NOT BILL YOUR HEALTH INSURANCE FOR PRIMARY CARE SERVICES PROVIDED UNDER THIS DIRECT PRIMARY CARE AGREEMENT.
 
This agreement does not provide comprehensive health insurance coverage, nor is it a contract of insurance. It provides only the health care services specifically provided by Immaculate Heart of Mary Family Health Center. Immaculate Heart of Mary Family Health Center will not bill insurance carriers for any services. If patients wish to seek reimbursement, they will be provided with office notes and a superbill (if appropriate) which patients can submit in an attempt to receive reimbursement from insurance companies or others. I understand that Immaculate Heart of Mary Family Health Center will not provide administrative support for these matters.
I understand that the Internal Revenue Service does not consider primary care monthly services fees eligible for payment with HSA, HRA, or FSA accounts.
It is highly recommended to maintain health insurance for unpredictable and catastrophic expenses.

5.    Termination of agreement.
I acknowledge and understand that both Immaculate Heart of Mary Family Health Center and I have the absolute and unconditional right to terminate this agreement, without the showing of any cause for termination. I may terminate my agreement with Immaculate Heart of Mary Family Health Center at any time and for any reason by providing written notice to Immaculate Heart of Mary Family Health Center, and the agreement will terminate at the end of the current payment month.
Immaculate Heart of Mary Family Health Center will not terminate this agreement solely based on health status. Immaculate Heart of Mary Family Health Center will assist transferring records and care to the new primary care physician designated by the patient. Any payments outstanding through the date of termination of the agreement are the responsibility of the patient

6.    Re-Enrollment
I acknowledge and understand that if I terminate my Immaculate Heart of Mary Family Health Centeragreement after receiving initial services, I may be allowed to reestablish my enrolled patient status only after payment of the rejoining fee of $100. I acknowledge and understand that Immaculate Heart of Mary Family Health Center is not obligated to allow me to reenroll if I have previously terminated my agreement.

Immaculate Heart of Mary Family Health Center
Vaccine Policy Statement

We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives. We firmly believe in the safety of our vaccines.

We believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention and the American Academy of Pediatrics.

We believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities.

We believe that thimerosal, a preservative that has been in vaccines for decades and remains in some vaccines, does not cause autism or other developmental disabilities.

We believe that vaccinating children and young adults may be the single most important health-promoting intervention we perform as healthcare providers, and that you can perform as parents/caregivers.

The recommended vaccines and the vaccine schedule are the results of years and years of scientific study and data gathering on millions of children by thousands of scientists and physicians.
This said, we recognize that there has always been and will likely always be controversy surrounding vaccination. The vaccine campaign is in many ways a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even discussing whether or not they should be given. Because of vaccines, many people have never seen a child with polio, tetanus, whooping cough, bacterial meningitis, or even chickenpox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent about vaccinating.

But such an attitude, if it becomes widespread, can lead to tragic results. After publication of an unfounded accusation (later retracted) that MMR vaccine caused autism in 1998, many Europeans chose not to vaccinate their children. As a result of under-immunization, Europe experienced large outbreaks of measles, with several deaths from disease complications. In 2012, there were more than 48,000 cases of pertussis (whooping cough) in the United States, resulting in 22 deaths. Most victims were infants younger than six months of age. Many children who contracted the illness had parents who made a conscious decision not to vaccinate. In 2015, there was a measles outbreak in Disneyland, California (probably started by an infected park visitor who had traveled from the Philippines). The outbreak eventually spread to 147 people and, again, many were too young to have been vaccinated.
When you don’t vaccinate, you take a significant risk with your child’s health and the health of others around them.

By not vaccinating, you also take advantage of thousands of others who do vaccinate their children, thereby decreasing the likelihood that your child will contract a vaccine-preventable disease.

We recognize that the choice of whether or not to vaccinate your children may be a very emotional one for some parents. Should you have doubts, please discuss these with your healthcare provider in advance of your visit. In some cases, we may alter the schedule to accommodate parental concerns or reservations. Please be advised, however, that delaying or “breaking up the vaccines” to give one or two at a time over two or more visits goes against expert recommendations, and can put your child at risk for serious illness (or even death) and goes against our medical advice as providers at Immaculate Heart of Mary Family Health center.

Such additional visits will require additional co-pays on your part. Please realize that you will also be required to sign a “Refusal to Vaccinate” acknowledgement in the event of lengthy delays.

Because we are committed to protecting the health of your children through vaccination, we require all of our pediatric patients to be vaccinated. Infants will receive all age-appropriate recommended vaccines by three months of age, with additional recommended vaccines as well as booster doses by two years of age. Children will receive additional recommended booster doses by the time they are seven years old, and will be given recommended 11–12-year preteen vaccinations by the time they are 13 years old. We will complete 16-year teen vaccinations before each child’s 17th birthday. And, we will also give your child/teen an annual influenza vaccination unless they receive it at a school clinic or pharmacy.

Finally, if you should absolutely refuse to vaccinate your child we will ask you to find another healthcare provider who shares your views. We do not keep a list of such providers, nor would we recommend any such physician. Please recognize that by not vaccinating, you are putting your child at unnecessary risk for life-threatening illness and disability, and even death.

As medical professionals, we feel very strongly that vaccinating your child on schedule with currently available vaccines is absolutely the right thing to do to protect all children and young adults. Thank you for taking the time to read this policy. Please feel free to discuss any questions or concerns you may have about vaccines with any one of us.

Do you suffer from any of the following conditions?

• Alcoholism
• Cerebrospinal fluid leak
• Chronic heart disease, including congestive heart failure and cardiomyopathies
• Chronic liver disease
• Chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma
• Chronic renal failure
• Cigarette smoking
• Cochlear implant
• Congenital or acquired asplenia
• Congenital or acquired immunodeficiencyB- (humoral) or T-lymphocyte deficiency
• Complement deficiency, particularly C1, C2, C3, or C4 deficiency
• Phagocytic disorder, excluding chronic granulomatous disease
• Diabetes mellitus
• Generalized malignancy
• HIV infection
• Hodgkin disease
• Iatrogenic immunosuppression, including long-term systemic corticosteroids and radiation therapy
• Leukemia
• Lymphoma
• Multiple myeloma
• Nephrotic syndrome
• Sickle cell disease or other hemoglobinopathies
• Solid organ transplant

Financial Responsibility Policy 

-If you use insurance, it is important to bring your insurance card to every visit. If you do not furnishproof of insurance at the time of your office visit you may be required to make a payment in full at thetime of the visit, or you may not be seen.

 -Co-payments and co-insurance, as well as services not covered by your insurance, must be paid in fullwithin 30 days of the time of service.

 -You understand that if you have a remaining account balance you may be asked to pay your account infull prior to seeing the provider.

 -You understand that billing codes will not be changed once they have been submitted to yourinsurance company.

Cancellation and No-show policy: 

Cancellation: We require 24-hour notice of cancellation for any appointments. If you cancel within 24 hours of your appointment, or do not show up for your appointment, the card on file that you have will be charged $50. You will also be considered a ‘No-show’ and will be subject to the no-show terms as outlined below. If you arrive more than 15 minutes late to an appointment without notification, the appointment will be considered a cancellation for these purposes. 

Late: You are considered ‘Late’ if you arrive any time after your stated appointment time. 

-If you are late, we may need to reschedule your appointment to a later timeslot.

-If you are more than 15 minutes late without notification, the appointment will be considered a cancellation.

 No-show: If you do not arrive for your scheduled appointment, do not provide our office with 24 hour notice of cancellation, or arrive more than 15 minutes after you scheduled appointment without notification, your appointment will be considered a no-show. 

-If you no-show to our office 3 times you will be discharged from our clinic.

Telecommunication, telephone, e-communication, and telemedicine agreements and consents: 

Immaculate Heart of Mary Family Health Center uses email, electronic patient portals, phone , texts, e-health, and telehealth platforms to communicate with our patients. Our goal is to make your medical care as streamline, convenient and efficient as possible. For this reason, we require your consent to contact you by those methods in various situations. 

You understand that, by signing below, you give your consent to Immaculate Heart of Mary Family Health Center to call, text, email, or use automated dialing systems and/or pre-recorded message to convey basic information relating to scheduling reminders, prescriptions and limited advertisements specifically regarding 

You understand that Immaculate Heart of Mary Family Health Center may employ 3rd party contractors to utilize automated outreach messages relating to upcoming appointments, missed appointments, balances due, lab results, or other healthcare related functions. 

You authorize Immaculate Heart of Mary Family Health Center to disclose limited protected health information (PHI) to 3rd parties relating to the above conditions. 

You agree to allow Immaculate Heart of Mary Family Health center to leave detailed messages on your voice mail, answering system, or with another individual if you are unavailable at the number you provide. 

You understand that your consent is specifically required in order to receive telehealth, virtual health, or telemedicine visits. 

Bioethics, contraception, PDE-5 agreement and consents

As a clinic that is committed to serving our patients within a Catholic bioethical framework, we derive many of our policies and procedures from the Ethical and Religious Directives of the Catholic Church (ERDs). A copy of the ERDs are available for free at www.usccb.org. 

You understand that our clinic and it’s staff will never deviate from any principle of the ERDs in our medical care for you. 

Contraception policy: 

You understand that Immaculate Heart of Mary Family Health Center, its employees, and all medical professionals that operate within, or represent in any way Immaculate Heart of Mary Family Health Center will under no circumstances provide or prescribe any medication for the purpose of artificial contraception. 

Furthermore, the staff at Immaculate Heart of Mary Family Health Center will not aid, refer or otherwise help to obtain artificial contraception in any way. 

Phosphodiesterase 5 inhibitors (PDE5) policy: 

PDE5 inhibitors are medicines commonly used to treat erectile dysfunction (ED). These medications include, but are not limited to, Viagra, Cialis, Stendra, and Levitra. 

It is the policy that Immaculate Heart of Mary Family Health Center, its employees, and all medical professionals that operate as representatives of Immaculate Heart of Mary Family Health Center will under no circumstances provide or prescribe any medication to unmarried men for the explicit treatment of erectile dysfunction. Furthermore, no referrals will be provided/generated, even if required by your insurance company, to obtain treatment explicitly for erectile dysfunction. 

For the purpose of this policy, marriage is defined as: a covenant by which a man and woman establish between themselves a partnership of the whole of life and which is ordered by its nature to the good of the spouses and the procreation and education of offspring. 

Card On File Agreement
 
Terms and Conditions:
 
I agree to allow Immaculate Heart of Mary Family Health Center (2175 N. Alma School Rd. Suite 109, Chandler, AZ 85224) to charge my credit, debit or flexible spending account card for services related to medical care that I have recieved at this organization. 
 
1.     My credit card will only be charged for fees that are not covered by your insurance company, and for services provided while this agreement is in effect.
 
2.     My credit card will only be charged once the final EOBs have been reviewed by Immaculate Heart of Mary Family Health Center.
 
3.     My credit card information will be stored within a secure processor affiliated with Immaculate Heart of Mary Family Health Center’s electronic payment processing vendors.
 
4.     My credit card will only be charged for bills that are 30 (thirty) days past due.
 
5.     I may cancel this agreement at any time by contacting Immaculate Heart of Mary Family Health Center; any unpaid amounts relating to non-covered services will be charged to the credit card on file at that time, or by another accepted payment method. This agreement will remain in effect until explicitly canceled by either party in writing.
 
6.     If at the time of signing this agreement, I have unpaid fees that are more than 30 days past due, I agree to have my credit card charged for the remaining balance of my account, unless another payment plan is agreed upon by both parties.

$50 cancellation or no-show fee: 

I understand that the card I have on file will be charged $50 if I cancel my appointment within 24 hours of the scheduled appointment, or do not show up to my apopiointment.