For a printable version please visit: https://bluestonemd.com/resources/enrollment-forms/

I understand that a patient may voluntarily designate or appoint an individual other than the patient to make medical decisions on the patient’s behalf. The individual may be referenced on the applicable authorizing paperwork using the following terms or other similar terms: Power of Attorney, Healthcare Surrogate, Healthcare Proxy, Healthcare Power of Attorney, Guardian, etc. (collectively referred to here as the “Legal Representative”). I acknowledge and agree that by signing this form as Legal Representative, I swear and attest that I am legally authorized to act and make decisions on the patient’s behalf. I am required to provide a copy of valid and effective documentation outlining my role as Legal Representative in order to receive related communications, including verbally and via the Bridge. The Bridge is where you can electronically contact Bluestone’s care team 24 hours a day, 7 days a week for questions, and is where the care team will connect with you about the patient’s care. Upon signing this form or any other required documentation from Bluestone as a Legal Representative for the patient, I hereby release and hold harmless Bluestone Physician Services and its representatives from any claims or damages arising from Bluestone’s reliance on my attestation that I am the patient’s Legal Representative. If there is a/you are the Legal Representative, please provide their/your contact information below:

Release Information To:

Bluestone Physician Services
Attn: Medical Records Dept.
270 Main Street N., Suite 300
Stillwater, MN 55082

FAX: 855-490-4045 PHONE: 877-599-1039

I hereby authorize the release of my individually identifiable health information described above for treatment and payment purposes. I understand that this authorization to release health information is voluntary. I understand that the information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by federal or state law.

I acknowledge and agree that by signing this form as a Legal Representative for the patient, I swear and attest that I am legally authorized to act and make decisions on behalf of the patient. I am required to provide a copy of valid and effective documentation outlining my role as Legal Representative in order to receive related communications. Upon signing the form or any other required documentation from Bluestone as a Legal Representative for the patient, I hereby release and hold harmless Bluestone Physician Services and its representatives from any claims or damages arising from Bluestone’s reliance on my attestation that I am Legal Representative.

Consent for Services and Disclosure of Information for Treatment: I consent to any and all medical evaluation and treatment, preventative care services and procedures which are deemed necessary or advisable by Bluestone medical providers and designees. I consent to the use of telemedicine services in the course of my diagnosis and treatment with my Bluestone Provider Team. Telemedicine involves the use of audio, video or other electronic communications to interact and consult with the healthcare provider(s). I also consent to the use and disclosure of my health information by Bluestone for my treatment, including disclosure of my health care information to health care providers and facilities unrelated to Bluestone that may be involved in care

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
BluestoneMD.com/forms.

If Legal Representative signing this form: I acknowledge and agree that by signing this form as a Legal Representative for the patient, I swear and attest that I am legally authorized to act and make decisions on behalf of the patient. I am required to provide a copy of valid and effective documentation outlining my role as
Legal Representative in order to receive related communications. Upon signing the form or any other required documentation from Bluestone as a Legal Representative for the patient, I hereby release and hold harmless Bluestone Physician Services and its representatives from any claims or damages arising from Bluestone’s reliance on my attestation that I am Legal Representative.

The Bridge and the Patient Portal are HIPAA compliant communication and health record systems where you and/or people you authorize can stay updated or access important health information online and access the Bluestone care team anytime. Both are very important tools for delivering high quality healthcare and keeping everyone informed. The primary way to reach your provider team is through the Bridge!

If patient is signing this form: I can authorize a personal representative to access my health care information and communicate with my Bluestone Provider Team electronically through the Bluestone Bridge and/or the Bluestone Patient Portal by filling out the PHI form with the appropriate information.

If Legal Representative signing this form: I acknowledge and agree that by signing this form as a Legal Representative for the patient, I swear and attest that I am legally authorized to act and make decisions on behalf of the patient. I am required to provide a copy of valid and effective documentation outlining my role as
Legal Representative in order to receive related communications. Upon signing the form or any other required documentation from Bluestone as a Legal Representative for the patient, I hereby release and hold harmless Bluestone Physician Services and its representatives from any claims or damages arising from Bluestone’s reliance on my attestation that I am Legal Representative.

This consent applies to health information Bluestone already has about me, information about future care I may receive from Bluestone and information Bluestone receives from third parties. This consent will continue unless I cancel by giving written notice to Bluestone Physician Services or it expires as required by law. Cancellation will apply after the date when the notice to cancel is received. It will not affect information that used or disclosed before cancellation.

REQUIRED: By signing below, you acknowledge the above and that you are giving the following individuals access to your health care records maintained by Bluestone, including updates on your health care status.