I acknowledge that by choosing any of the above options I give Contemporary Medicine Associates authorization to contact me via the selected method(s)
I voluntarily consent to receive medical and health care services that may include diagnostic procedures, examinations and treatment
This consent form authorizes Contemporary Medicine Associates ("CMA") to obtain and review my prescription history. Detailed prescription history provides your physician with information about medications being prescribed by other providers involved in your medical care. This information will improve the accuracy of our medication list in your medical chart and decrease any adverse drug reactions or inaccurate medication information such as medication names or dosages.
By signing this consent form, you agree that CMA can request and use your prescription medication history from other healthcare providers, pharmacies, and benefit payers (such as your insurance company) for treatment purposes.
Understanding the above, I hereby provide informed consent to CMA to request, view, and use my external prescription history for treatment purposes.
I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I can request a copy of this notice at any time. I have the right to review the notice prior to signing this consent. I have had the opportunity to receive and review the Notice of Privacy Practices of Contemporary Medicine Associates.
Keeping information private is important to us and by default we will only disclose information related to the patient’s billing account and medical conditions to the patient or legal guardian. Please note, to share protected health information with your spouse they must be listed as an approved contact.
The following names are people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for CMA to share my protected health information with:
I have carefully reviewed this document and agree to fully comply with guidelines defined herein related to the Assignment of Benefits, Financial Policy, HIPAA Policy, and Approved HIPAA contacts. The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for health information from persons not listed on this form will require my specific authorization prior to the disclosure of any personal health information.
To sign up for access to your health information through our secure patient portal complete the first portion of this form
Thank you for choosing us as your healthcare providers. We are committed to providing you with quality and affordable healthcare. The following are our Financial and Office Policies. Please read, initial on the right and sign at the bottom. Please ask us any questions that you may have.
Patient Responsibility: We participate in many insurance plans. We recommend you become familiar with your insurance benefits and confirm our participation with your plan. Most misunderstandings about insurance can be avoided if you understand what your policy covers. Please contact your insurance company with any questions you may have regarding your coverage.
Insurance Carriers Requiring Referral: If you are referred to a specialist and your insurance carrier requires a referral number, please give our office at least a 48-hour notice to complete that referral.
Proof of Identity and Insurance: All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your valid government issued identification and a current, valid insurance card, if applicable. Please bring these items with you to each visit. Payment in full is required if we are unable to verify your current insurance information.
Payments due at the time of service: Co-pay, deductible, co-insurance, and cash pay services. A Good Faith Estimate (GFE) is available and will be supplied if applicable.
Nonpayment & Returned Checks: Unpaid accounts will be referred to an outside collection agency and could result in dismissal from the practice. There will be a $25 fee for all returned checks.
Late Arrivals: Please arrive at least 10 minutes prior to your scheduled appointment time. If you arrive late to your appointment, our office may have to reschedule your appointment to a new time or date. If the appointnment is rescheduled due to late arrival, this constitutes as a no show and will result in a $250 no show fee.
No shows: Please notify us 24 hours in advance if you must cancel or change your appointment time. Failure to do so will result in a $250 no show fee that is not covered by your insurance. A third no show may result in dismissal from the practice.
Form completion. All forms requiring medical review and physician signature – including school, day care, and camp physicals, prior authorizations, FMLA, disability or other paperwork – may be subject to an administrative fee of $35.00.
Policy: I have read and understand the Financial and Office Policies of CMA and agree to abide by its guidelines
A Copy is Available Upon Request