Patient Forms

Acknowledgement for the Use and Disclosure of Health Information

The Department of Health and Human Services has established a “Privacy Rule" To help insure that personal health care information is protected for privacy. The Privacy Rule was also created to provide a standard for certain health care providers to obtain their patients' consent for the uses and disclosure of health information about the patient to carry out treatment , payment, or health care operations.

As our patients, we want you to know that we will respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We make every effort to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information n t o only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.

I(Please print name here) have had full opportunity to read and consider the contents of Respacare Notice of Privacy Practices. I understand that, by signing this form, I am acknowledging, and allowing the disclosure of my protected health information may be released to carry out treatment, payment activities, and health care operations.

Signature

Date:

If a personal representative on behalf of the patient is signing this acknowledgement, please complete the following:

Personal Representative’s name

Relationship to patient :

Note: Anyone wishing a copy of Section / "Uses and Disclosures of HIIPPA", please advise the receptionist.

I understand that if I fail to cancel my scheduled appointment within 24 hours, I will be charged $50.00 . I understand that Medicare and other insurance companies will not reimburse me for missed appointments. I understand that these charges are my full responsibility. By signing this I am agreeing to these terms.

Please initial

I understand that if my check is returned from the bank, for any reason, my account will be charged $35.00 in addition to the money owed.

Please initial

I understand that it is my responsibility to pay any co-pays, coinsurance and deductibles at time of service. If my account should become past due by 90 days. I understand that the practice will charge a 5% interest on these charges. I understand that Medicare and other insurance companies will not reimburse me for this interest. By signing this I am agreeing to these terms.

Please initial

I understand that if my insurance company requires that I need a referral for an office visit or procedure, I will provide Respacare with a valid referral and make sure I have a valid referral at time of visit. I understand it is my responsibility to make sure I have a valid referral time of service and if I do not, I understand that my insurance company will not pay Respacare and I will be fully responsible for the visit. By signing this I am agreeing to these terms.

Please initial

I understand that RespaCare will make every effort to explain the cost of a procedure or medication. It is my responsibility to be aware of my insurance company's reimbursement guidelines and acknowledge I am fully responsible for anything they will not cover. By signing this I am agreeing to these terms.

Please initial

I understand that you will contact me through the phone numbers that I have provided you and consent to the staff of Respacare leaving messages on these numbers in regards to the treatment and / or payınent.

I understand if I am non-compliant with office visits and plan of care orders that Respacare is not responsible for medication or Specialty Pharmacy refill requests.

Please initial

Patient name

Patient Signature

Date:

(*) Fields Are Mandatory

Permissions

A) I hereby give Respacare permissions to release and/or discuss any medical information to the following contacts below:

Print Name:

Relationship to Patient

Print Name:

Relationship to Patient

B) In addition, messages pertaining to my treatment and appointments may be left on:
(Please check all that apply)

Home Phone:

Work Phone:

Cell Phone:

Patient's Name (Please Print)

D.O.B.

Patient's Signature

Date

(*) Fields Are Mandatory