Volland & Associates, Inc. Signature on File and Assignment of Benefits Agreement

Transcription

1 Signature on File and Assignment of Benefits Agreement Kindly accept a photocopy of this authorization as if it were an original executed authorization. I understand that Volland & Associates, Inc. utilizes computerized billing, therefore, my signature below acts as a signature on file. I authorize the release of any payment and medical information necessary to process claims and claim related items for myself and/or my family members. I hereby authorize payment directly to Volland & Associates, Inc. of the insurance benefits otherwise payable to me for their professional services. I understand that I am financially responsible to Volland & Associates, Inc. for all charges not covered by this assignment. In the event that my insurance company fails to meet its obligations with respect to payment of my claims, I give permission to Volland & Associates, Inc. to file a complaint to the State Insurance Commissioner using my name as the complainant. I also understand that I will be informed, in writing, if this occurs. Patient/Guardian Signature

2 Treatment Consent Form Explanation of Consent Form: This treatment form covers all procedures that are not of a nature to require a special consent, and it provides protection for the procedures performed by the professional staff of Volland & Associates, Inc. This form documents that the client has consented to treatment at Volland & Associates, Inc., including but not limited to, psychotherapy and counseling. This allows the professional staff at Volland & Associates, Inc. to provide services to you. This form provides evidence that no guarantee is made by any professional at Volland & Associates, Inc. concerning the outcome of treatment. There is no guarantee that treatment will be successful. This form also provides evidence that consent is given only after a full explanation has been provided by the staff at Volland & Associates, Inc. If you have any questions concerning this or any other matters, it is your responsibility to ask your therapist. By signing this form, you acknowledge that you understand you consent to treatment as explained in this form. Consent to Treatment: I,, for, Print your name here Print patients name if other than yourself do hereby, voluntarily consent to care and treatment by Volland & Associates, Inc. professional staff. I am aware that the practice of medicine, psychiatry, clinical psychiatry and clinical social work is not an exact science and I acknowledge that no guarantees have been made as to the result of evaluation or treatment. I am aware that I am an active participant in the counseling process and that I share responsibility for treatment. My responsibilities include informing the therapist of any information that may be relevant to the problems or conditions being treated, assisting in setting goals for treatment, following therapeutic advice to the best of my ability, and ending treatment in a responsible way. If I am in consenting to treatment for another person or for a child, I certify that I am legally responsible for that person or child, and am entitled to consent to treatment for them. I certify that I fully understand the contents of this form. I also understand that it is my sole responsibility to ask any questions or obtain any clarification necessary to my understanding this form fully. Sign your name

3 Volland and Associates, Inc. Financial Responsibility Agreement Please read carefully By signing this agreement you agree to, or understand that: Volland & Associates, like all provider offices, operates on appointments. If you are more than 10 minutes late for an appointment, you will need to be rescheduled. This allows our schedule to run as efficiently as possible and decreases wait times. The appointment made for you is time that is reserved for you with the therapist. If you are not able to keep this appointment, please give us 24 hours notice. If you do not provide 24 hours notice of a cancellation or rescheduling of an appointment, there will be a $50.00 charge. Your insurance company will not cover this charge. If this occurs two consecutive times you will be dismissed from this practice. To inform us immediately of any changes regarding your address or phone number. To assume financial responsibility for all charges that may be incurred for treatment rendered to you and/or your family members. You understand that your patient status will change to inactive if you go more than 60 consecutive days without an appointment. By utilizing your insurance benefits: You agree to notify us at least 48 hours in advance of any changes to your insurance. Some examples of this type of change would include: switching from one insurance company to another, termination of your policy, picking up a secondary insurance, etc If you fail to notify us of changes 48 hours in advance of insurance changes you will be charged the self-pay rate for that day s service. You understand that it is considered insurance fraud if you do not disclose all insurance coverage. If you have active insurance coverage with more than one insurance company you must disclose all coverage to us. You cannot choose to use one insurance company and not the other; doing so is fraudulent and generally results in a large out of pocket expense to you. You understand that your insurance carrier will be billed for each of your visits, but that you are personally responsible for the amount that your insurance company considers your patient responsibility as defined in your contract on the date of your appointment. This means we require all copays, co-insurance payments, and deductible payments, be paid on the day of your appointment. We do not bill for these payments. You understand that your insurance company will periodically send you questionnaires or other inquiries by mail. If you do not fill out and return these inquiries to your insurance company they will not pay for your treatment thus making you financially responsible for 100 percent of the charges for your visits. Print Patient Name Patient/Guardian Signature

4 NOTICE OF PRIVACY PRACTICES Disclosures of your medical information that we may make without your authorization. Payment: In order to get your healthcare services paid for, we may have to provide your medical information to the party responsible for paying. Your insurance company or health plan may need your information for activities such as determining your eligibility for coverage, reviewing the medical necessity of the healthcare services. We may share your protected health information with third parties who perform services such as transcription or billing. In those cases we have written agreements with the third parties that they will not use or disclose your information for any other purposes, except as required by law. Required by Law: Your medical information may be used or disclosed by us when required by law. If this happens, we will comply with the law and will only disclose the information necessary. You will be notified, as required by law, of any such uses or disclosures. Health Oversight: Health oversight agencies are authorized to have access to medical information maintained by us for activities such as audits, investigations, and inspections. Agencies with this authority include government agencies that oversee the healthcare system, government benefit programs, government regulatory programs and civil rights laws. Abuse or Neglect: We may disclose your medical information to a public health authority that is authorized by law to receive reports of child abuse or neglect. How we will use and disclose your medical information with authorization. Other uses and disclosures of your medical information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke the authorization, at any time, in writing, except to the extent that we have already taken an action in reliance on the use or disclosure indicated in the authorization. Complaints: Office for Civil Rights U.S. Department of Health and Human Services 2201 Sixth Avenue - M/S: RX-11 Seattle, WA For a summary of the HIPPA Privacy Rule visit: By signing this document you acknowledge only that you have been made aware of the privacy policy. Your signature does not imply that you agree with the privacy policy. You may request a copy of this notice for your records at any time. Patient Name Patient/Responsible Party Signature

5 HIPAA Privacy Authorization Form Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act 45 CFR Parts 160 and 164) I hereby authorize Volland & Associates, Inc., to release any and all information, clinical observations, and psychotherapy notes, to my insurance company, or employee assistance program as required by those organizations for the purpose of treatment review and claims payment. I further authorize Volland & Associates Inc., to release any and all information, clinical observations, and psychotherapy notes to: Primary Care Physician: (include phone #) Other Physician: (include phone #) example: friend, spouse, mother, attorney, etc. ) I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that the information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. This authorization shall be in force and effect for a maximum period of two years from the date signed. Signature of Patient or Guardian of Minor Print name of Patient or Guardian of Minor Relationship to Patient