Formulario de paciente nuevo Formularios de consentimiento

CONSENT TO MAIL MEDICATIONS TO MY HOME GENERAL INFORMATION

GENERAL INFORMATION

Patient understands Apex Orthopaedics Spine & Neurology (“Provider”) is licensed to dispense certain medications (“Medications”). Patient understands Provider is willing to mail Medications to Patient’s home address via First - Class Mail. Patient understands there is a risk, however, that: (i) someone may steal Medications out of Patient’s mailbox, (ii) a family member or other person authorized to collect the mail from Patient’s mailbox may wrongfully take Medications, (iii) Medications may get lost or stolen in transit from their office to Patient’s mailbox, or(iv) Medications may be delivered to the wrong address. Additionally, a collateral risk of mailing Medications is that Patient’s Protected Health Information(PHI) is discovered by an unauthorized party. Patient understands Provider is not responsible if sending Medications results in an unauthorized person seeing Patient’s PHI or obtaining Medications. Knowing these risks and accepting the liability and responsibility for same, Patient agrees and authorizes Provider to mail Patient’s Medications to Patient’s home address.

ACCEPTANCE, CONSENT, AND WAIVER

Patient agrees to allow Provider to mail Patient’s prescriptions directly to the address Patient provided. This mailing will include Patient’s PHI, such as Patient’s name and the medication that Patient am taking and may include other sensitive facts about Patient’s health. Patient understands that if another person accesses Patient’s prescription, that person will see Patient’s PHI. If Patient do not want to accept the risk that someone may take Patient’s prescription and/ or access Patient’s PHI, Patient should not agree to allow Provider to mail Patient’s prescriptions to Patient.

Patient accepts these risks and agrees that Provider may mail Patient’s prescriptions to Patient via First-Class Mail. Patient agrees to inform Provider immediately if Patient’s address changes. Patient will not hold Provider responsible if Patient’s PHI is seen by an unauthorized person or Patient’s medications are taken/ obtained by an unauthorized party. Patient RELEASES, WAIVES, DISCHARGES AND PROMISES NOT TO SUE OR BRING ANY CLAIM OF ANY TYPE AGAINST PROVIDER FOR LOSS, DAMAGE, INJURY, OR LIABILITY RELATING TO THE MAILING OF MY MEDICATIONS TO MY DESIGNATED ADDRESS.

This form gives you the facts and risks involved in receiving Patient’s Medications by mail. By accepting this form, Patient confirms that Patient has read, understands, and agrees with these Terms of Use for receiving Patient’s Medications by mail.

GENERAL INFORMATION

I understand that at my direction my Provider will transmit my prescriptions electronically as permitted, to the pharmacy that I delegate as my primary pharmacy provider. Prescription data collected will be stored in Provider’s practice electronic medical records system and will become a part of my personal medical record. I hereby give permission to allow Provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. By signing this consent, I give Provider permission to collect and give my pharmacy and health insurer permission to disclose information about my prescriptions that have been filled at any pharmacy or covered by any health plan. This includes prescriptions to treat AIDS/HIV and medications used to treat mental health issues.

THE INFORMATION I HAVE PROVIDED IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND ABILITY. I HAVE READ/COMPLETED OR HAVE HAD THIS ACKNOWLEDGEMENT AND CONSENT FORM READ/ COMPLETED FOR ME AND IT HAS BEEN EXPLAINED TO MY SATISFACTION AND APPLIES TO ALL MEDICAL PROFESSIONALS EMPLOYED BY PROVIDER.

Patient assigns and appoints Apex Orthopaedics Spine & Neurology (“Provider”), as its authorized representative and billing agent with the right to pursue payment for benefits, and take any and all necessary steps, including pursuing administrative appeals, requesting disclosures and remedies, filing suit and all causes of action wholly in my stand for benefit payment of all medical benefits otherwise payable to the Patient for medical services, treatments, therapies, and/or medications rendered or provided by the Provider under the Plan, regardless of the Provider’s managed care network participation status. The Patient hereby appoints the Provider, its billing agent and/or the Patient’s appointed business associates, the Patient’s rights, title, and interests in and to, and related to the recovery of, any and all benefits which the Patient is entitled to receive under the Plan or insurance policy and authorizes the Provider to release all medial information necessary to pursue and process the Patient’s benefits and claims thereunder. Patient certifies that the health insurance information that Patient provided is accurate and that Patient is responsible for keeping it updated. Patient hereby authorize Provider to submit claims on Patient’s behalf to the benefit plan (or its administrator) to be paid in full compliance of governing laws. Patient also hereby instructs its benefits plan (or its administrator) to pay the Provider directly for services rendered to Patient. To the extent that my current policy prohibits direct payment to provider, Patient hereby instructs and directs its benefit plan (or its administrator) to provide governing plan documentation stating such non-assignment to Patient and the Provider upon request and its standing to governing laws. Upon proof of such non-assignment, Patient instructs benefit plan (or its administrator) to make check payable to Patient and mail it directly to Provider. Patient understands there are state and federal consumer protections that support even for out of network providers that may be associated with Patient’s care or surgery, that Patient is responsible for co-payments, co-insurance, and deductibles at no more than Patient’s in-network cost share rate. Patient understands, agrees and hereby certifies that Patient is obligated to pay, as charge and billed for global service charges, regardless of if the above services are covered under Patient’s health insurance or plan. Patient understands that “Deductible” is defined, under the Uniform Glossary from ERISA & the Patient Protection & Affordable Care Act (“ACA”) as: “The amount [Patient] owes for healthcare services [Patient’s] health insurance or plan covers before [Patient’s] health insurance or plan begins to pay,” and that Patient has no knowledge of any plan exclusion or limitation for the charges for healthcare services rendered by the above listed provider, in case that Patient can’t afford to pay 100% deductible. Patient understands the payments are due at the time of the services unless otherwise applicable to any PPO or ACA discount once Patient’s claim for benefits is processed in full compliance with plan terms and governing laws. Patient understands Patient is fully protected against any unexpected medical bills or charges by my provider’s appliable ACA or indigency discount policy; including any non-complaint or arbitrary and capricious PPO discount of Re-pricing Discounts received from Patient’s health insurance plan. Patient’s satisfaction is guaranteed in connection with Provider’s proactive reasonable efforts to collect or make a good faith determination for ACA Discount qualifications solely based on Patient’s unique ability to pay and individual health need. Patient hereby assigns billed charges for healthcare services rendered as Patient’s legal claims to the above listed Provider as full payment, as Patient authorized representative, and an ERISA or ACA claimant, to claim or legally pursue proper payment of benefits from my health plan or insurance.

Patient hereby designates, authorizes and appoints Provider, its attorney or other designated business associate and a Patient’s authorized representative to: (1) release any information necessary to Patient’s health benefit plan (or its administer) regarding Patient’s illness and treatments; (2) process insurance claims generated in the course of examination or treatment; (3) To file and participate in any administrative or judicial review process; (4) to give the provider and its attorneys standing to pursue payment and file suit for benefits and any fiduciary breach and all causes of action, wholly in Patient’s stead; (6) to pursue a claim for benefits and to recover all applicable penalties for any fiduciary breach and all causes of action available under ERISA and Section 502, 27 § U.S.C. 1132(a); (5) to pursue all necessary benefit payments, appeal rights, remedies and all causes of action, wholly in Patient’s stead; (6) to pursue a claim for benefits and to recover all applicable penalties for any fiduciary breach or failure by Patient’s plan, its fiduciary and/or its claims administrator to comply with 29 USC § 1132 and (7) allow a photocopy of Patient’s signature to be used to process insurance claims. This authorization includes all entitled benefit payments, rights and remedies due under Patient’s governing Health and Welfare Plan or policy, to include all benefits entitled for all services rendered and ordered by Patient’s treating physician. This authorization will remain in effect until all benefits are paid in full compliance of applicable federal and state laws. Patient hereby confirms and ratifies all actions taken by Patient’s Provider, its attorneys or designated business associates to make any request, file and obtain appeals information, receive any notice in connection with patient’s healthcare services, benefits, appeals, take legal action or other rights, wholly in Patient’s stead. Further, Patient hereby authorizes Patient’s plan administrator, fiduciary, insurer, and/or attorney to release to the above-named health care provider or its designated business associated in any and all relevant Plans and claim documents, requested disclosures, complete insurance policy, and/or settlement information upon request from Provider, its attorneys or designated business associate in order to secure and claim such medical benefits. Patient authorizes the release or disclosure of Patient’s protected health information to Patient’s authorized representative in order to secure and claim medical benefits due: (1) obtain information or submit evidence regarding the claim to the same extent as Patient; (2) make statements about facts or law; (3) act as Patient’s authorized representative in connection with filing, providing or receiving notice of any claim or appeal proceedings, to include any external review by applicable state and Federal External Review Process. I understand that I will be held financially responsible for all fees accumulated for collection agency fees. Administrative fees, attorney fees and court costs incurred by the provider listed above for any delinquent account requiring outside collection assistance, to the fullest extent of the law. Patient understands revocation of this appointment will not affect any action taken in reliance on this appointment before Patient’s written notice of revocation is received. Unless revoked in writing, this assignment is valid for any and all requested administrative and judicial reviews rightfully due to Patient under Patient’s governing plan or policy and to the fullest extent permitted by law. Patient, by signing this form, confirms appointment of authorized representative, the scope of Patient’s authorized representative’s authority, and the option of revoking of this appointment.

Patient understands Provider will attempt to obtain eligibility information, authorizations, and referrals on Patient’s behalf. Patient understands that it is in Patient’s best interest to verify with Patient’s insurance carrier what Patient’s benefits are and if Provider is participating on Patient’s plan. Provider does not guarantee benefits or coverage at the time of service. Patient also understands that any amounts not paid by Patient’s health insurance or plan is Patient’s responsibility and such payment is due at the time of service.

Patient hereby assigns and authorizes payment directly to Provider of: (i) any private healthcare insurance, (ii) medicalpayment insurance, (iii) injury benefit due because of liability of a third-party, and (iv) proceeds of all claims resultingfrom the liability of a third party, payable by any party, organization, attorney, etc., to or for Patient, unless and until Patient’s account with Provider for the services or series of related services provided by the Provider (collectively, the “Services”) is paid in full, upon discharge or completion of the Services. Patient hereby authorizes Provider to apply and file for allsuch payments referenced herein on Patient’s behalf, and direct that such payments be made directly to Provider.

Patient understands that by receiving services provided by Provider (collectively, the “Services”) PATIENT is personallyresponsible for any portion of the Provider’s invoice(s) for Services that remains outstanding. Patient further agrees to execute any necessary documents to direct all third-party benefits and other payments for Services to Provider.

Patient understands that Provider has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. If a lawsuit is filed to collect on Patient’s account, exclusive jurisdiction shall be in the state and federal courts of North Carolina. Patient waves all objections to personal jurisdiction and venue in North Carolina. Patient agrees to pay Provider’s reasonable attorneys’ fees and costs incurred collecting on any outstanding amounts due to Provider.

In accordance with the Health Insurance Portability and Accountability Act (HIPAA), by accepting this form, Patientacknowledges that Patient was given access to and offered a copy of the Notice of Privacy Practices for Apex Orthopaedics Spine & Neurology.

Patient hereby authorize Provider to leave Protected Heath Information (“PHI”) pertaining to Patient’s care by voicemail/email/text and will assume responsibility to notify them whenever this information changes. Patient authorizesProvider to leave messages with the person(s) Patient has designated as Patient’s approved contacts or emergency contacts. Patient understands that PHI used or disclosed pursuant to this Authorization may be subject to re-disclosure bythe recipient and no longer protected by Federal or State Law. Patient understands that Patient have the right to revokethis authorization at any time. Patient understands that in order to revoke this authorization, Patient must do so inwriting and present Patient’s revocation to Provider. Patient understands that the revocation will not apply to information that has already been used or disclosed in response to this authorization. Patient understands that this authorization isvalid unless and until written notice is provided to revoke this authorization. Patient understands that Provider cannot require Patient to sign this authorization as a condition of treatment unless the provision of health care by Provider is for the sole purpose of creating PHI for disclosure to a third party legally authorized to receive such information.

By providing a telephone number, Patient expressly consent and authorize SIS, any practitioner or clinical provider as well as any of their related entities, agents, or contractors including but not limited to schedulers, debt collectors, and other contracted staff (collectively referred to herein as “Provider”) to contact Patient through the use of text messages and any dialing equipment (including a dialer, automatic telephone dial system, and/or interactive voice recognition system) and/or artificial or prerecorded voice or message. Patient expressly agree that such automated calls and/or text messages may be made to any telephone number (including numbers assigned to any cellular or other service for which Patient may be charged for the call) used by or associated with Patient and obtained through any source including but not limited to any number Patient is providing today, have provided previously, or may provide in the future in connection with the medical goods and services and/or Patient’s account. By providing this express consent, Patient specifically waives any claim Patient may have to the making of such calls, including any claims under the federal or state law and specifically any claim under the Telephone Consumer Protection Act, 47 U.S.C. § 227. By providing a telephone number, Patient represent that Patient is the subscriber or owner or have the authority to use and provider consent to call the number.

By providing Patient’s email address now or at any time in the future in connection with the medical goods and services provided and/or Patient’s account, Patient expressly opt-in to the receipt of email communications from Provider for or related to the medical goods or services provided, Patient’s account, and other services such as financial, clinical, and education information including news, changes to health care laws, health coverage, care follow-up, and other health care opportunities, goods, and services. By providing this express consent, Patient specifically waives any claim PATIENT may have for the sending of such emails, including any claim under federal or state law and any claim under the CAN-SPAM Act, 15 U.S.C. § 7701, et. seq. By providing an email address, Patient represents that Patient is the subscriber or owner of have the authority to use and provider consent to contact the email address.

Patient understands that providing a telephone and/or email address is not a condition of receiving medical services. Patientunderstands that Patient may revoke Patient’s consent to contact at any time by directly contacting Provider or using the opt-out method that will be identified in the applicable communication. Patient also understands that it is Patient’s responsibility to notify Provider immediately of any change in telephone number or email address.

Allow for other individuals to access information as designated by the patient.

I authorize the release of medical record(s) of the above person. This information is being released to APEX ORTHOPAEDICS, SPINE & NEUROLOGY for purpose of continued medical care.

“I understand that I have the right to revoke this authorization at any time by presenting a written revocation to the Medical Records Director or designee. I understand that the revocation will not apply to any information that has already been released in response to this authorization.”

This expiration will expire one (1) year from the date of my signature.

“I have read and understand the contents of this authorization and I confirm that the health care provider may use/disclose my protected health information to the persons and/or organization named above.”

Please release to:

Apex Orthopaedics, Spine & Neurology

Dr. Erik Bendiks, Dr. Joshua Levy, Dr. Thai Truong,

11650 Alpharetta Hwy

Roswell, GA 30076

Email: clinical@apexosn.com

Phone: 704-272-3880

Fax: 704-208-4159