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2. Please "SUBMIT" form when complete. Do not leave page until receiving a "Thank You" message.
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I agree to Center for Women's Health policies. I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in this registration form or during communications with Center for Women's Health staff could impact my care negatively and/or result in discharge from the practice.
CONSENT FOR TREATMENT: I consent to and authorize my health care provider to examine and treat patient listed below. I understand that this could include lab tests, education, or other diagnostic procedures. I understand that my provider is available to explain the purpose of the procedures and treatment, and that I have the right to refuse their commended treatment.
PHYSICAL EXAMINATION: We are a treatment centric facility. Please have patience with us as we gather a comprehensive history, perform a physical examination, and order any clinical studies that may help in your care. Please inform a staff member of any issue with having an exam or sharing medical history.
ORDERS - LABORATORY AND ULTRASOUND: Clinical studies may be required for us to provide you with the best care possible. Often these studies are performed at a different facility. We apologize for any inconvenience that may cause. If you cannot complete the orders for any reason, please inform a staff member.
ELECTRONIC PRESCRIBING: I authorize Center for Women's Health (CFWH) to retrieve my medication history through their e-prescribing system and enter it into my electronic medical record.
SERVICES: Charges from Center for Women's Health (CFWH) are solely in relation to professional services rendered by a CFWH provider, and or other services that are performed in the CFWH clinic. All other services that require the patient to go elsewhere such as lab work, x-rays, MRI’s, CT’s, etc., are not included in the CFWH fee. Patient is responsible for all fees billed separately from the practicing location.
AMOUNT DUE: CFWH policy is to collect all patient responsibility amounts at the beginning of each appointment. Best efforts will be made to communicate the amount prior to the day of the appointment. However, some factors may change the amount due (ie personal insurance benefits, additional diagnosis or procedures). CFWH will kindly reschedule a patient appointment, if unable to remit co-payment or any past due balances. CFWH accepts cash and most major credit cards. Payment will include any unmet deductible, co-insurance, co-payment amount, and charges not covered by patient's insurance company. Inusrance is a contract between the patient and the insurance company and ultimately the patient is legally responsible for payment in full.
CLAIMS and BILLING AUTHORIZATION: As a courtesy to our patients, CFWH will file a claim for services provided with patient's carrier on file at the time of service. CFWH reserves the right to accept retroactive coverage at its own discretion. The patient is responsible for seeking reimbursement covered by retroactive coverage if not accepted by CFWH. This agreement authorizes CFWH to release requested medical information to patient's insurance company to collect payment for any charges incurred.
ASSIGNMENT OF BENEFITS
I hereby request payment of insurance benefits be made directly to Center for Women’s Health on my behalf for any services provided to me. I acknowledge and understand that I am financially responsible for all charges relating to the service(s) rendered to my dependent or myself. If, for any reason, my insurance carrier (including Medicaid or Medicare) does not pay any portion of my bill within 60 days of submittal, the responsibility of payment transfers to me and I agree to pay promptly. Interest will accrue beginning 30 days after transfer of payment responsibility at a rate of 5% APR. CFWH reserves the right to refer any amounts due to a collection agency and at such time the agency fees will apply.
**IT IS YOUR RESPONSIBILITY TO BE AWARE OF YOUR INSURANCE BENEFITS.**
It is your responsibility to notify our office, if there is a change in your insurance coverage, residence, or phone number. I have read and I understand the above FINANCIAL POLICY and I agree to abide by its terms.
EMERGENCY - Person to contact in the event of an emergency and who has authority to make healthcare decisions for the patient.
HIPAA - I hereby authorize Center for Women's Health to communicate information regarding my healthcare with individuals listed below.
PATIENTS’ RIGHT TO PRIVACY: Any and all information collected at this site will be kept strictly confidential and will not be sold, rented, loaned, or otherwise disclosed except for its intended purposes of providing healthcare and collecting payment for services provided. Any information you give to Center for Women's Health, LLC will be held with the utmost care.
I acknowledge I have been made aware of Center for Women's Health privacy practices. I agree if I want a copy it is my responsibility to ask. A more detailed explanation of the privacy practices are posted in the reception area.
By providing an eMail address, I agree to receive messages from Center for Women's Health. Any and all information collected at this site will be kept strictly confidential and will not be sold, rented, loaned, or otherwise disclosed except for its intended purposes of providing healthcare and collecting payment for services provided. Any information you give to Center for Women's Health, LLC will be held with the utmost care.
K-Mart does not accept Medicaid. Please select a different Pharmacy.
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