ASSIGNMENT OF BENEFITS, AUTHORIZATION TO RELEASE MEDICAL INFORMATION:
I request that payment of authorized benefits from my insurance carrier be made either to me or on my behalf to Urology Associates of Central MO for any services furnished to me by my provider. I authorize any holder of medical information about me to release it to the following when applicable to determine benefits for related services: Division of Family Services, Centers for Medicare and Medicaid Services, insurers and/or agents of these companies, responsible person(s) listed, Name of authorized person (specify relationship) or other healthcare providers assisting in my medical care.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES:
I have been offered a copy of Urology Associates of Central MO Notice of Privacy Practices.
CONSENT TO TREATMENT:
I authorize Urology Associates of Central MO and/or any physician or authorized persons employed by them to perform and/or initiate medical evaluation and treatment and authorize and/or order any related services on my behalf.
In the event that any personnel assisting in the provision of care and treatment suffer inadvertent exposure to any of my blood and/or other bodily substances that is capable of transmitting disease and I am unable to timely consult with my physician prior to testing, I consent to limited testing to determine the presence, if any, of antibodies to or infectious agents of hepatitis A, B, C and HIV.
I understand that in order for Urology Associates of Central MO to comply with the federally mandated initiative for electronic medication prescribing (e prescribing) software to send prescriptions over the internet to pharmacies. These transmissions are done in a safe manner that protects the privacy of personal information. I agree that Urology Associates of Central MO may request and use my prescription history from other healthcare provides or third party payers for treatment purposes as required by the above mentioned federal initiative.
I understand that I am financially responsible for any charges regardless of insurance coverage. Should I default, I agree to pay all cost of collections including interest applied by collection agency, court cost and attorney fees. Any suit filed may be brought in the county where services are rendered. I also understand and acknowledge that I am personally responsible to pay Urology Associates of Central MO in full for services that my health insurer will not cover due to non-payment of my health insurance premiums.
I have read and agreed to the provisions on listed on this form and accept the terms. A duplicate of this statement is considered the same as original.