Notice of Privacy Practices and Consent (Acknowledgment of Receipt): I received a copy of Bluestone’s Privacy Practices and understand I have a right to review these before signing this consent form. I understand that Bluestone may change its privacy practices in the future, that any changes will be posted on Bluestone’s website and that I may request a copy of the new privacy practices at any time. I understand I can contact Bluestone’s Privacy Officer with any questions I may have about the Notice of Privacy Practices. In addition to the other uses and disclosures described in this document, I consent to the use and disclosure of my health information for the purposes described in the Notice of Privacy Practices, including Bluestone’s health care operations.
Patient Financial Consent: I understand that it is my responsibility to know what the terms of my insurance are, and in compliance with those terms, I understand I will pay all applicable co-pays or co-insurance and outstanding account balances as they become due. I understand that it is my responsibility to read and review the Bluestone Physician Services (BPS) Patient Financial Consent policy located online at BluestoneMD.com and agree to be bound by its terms.
Use of Health Care Records in Program Evaluations and
Training: I give Bluestone permission to use and disclose information gathered during the course of my treatment from Bluestone, including information from my treatment records, for the purposes of program evaluation and training and for overall quality review, including staff performance and outcomes at Bluestone.
Chronic Care Management: I give Bluestone permission to enroll me in the Bluestone program which includes chronic care management (CCM) when appropriate. The program and CCM include practitioner/ care management visits and activities, which will be billed to my insurance with normal deductibles and copays.
I understand that only one practitioner may furnish and be paid for CCM services during a given calendar month and that I have the right to stop CCM services at any time. I understand information concerning this program is available on the website at