Patient Consent and Authorization

Please correct the errors described below.

3775 45th Ave.
Columbus, NE 68601
402-564-7200

have a condition requiring diagnosis and medical or surgical treatment, do hereby voluntarily consent to such diagnostic procedures and clinic care and to such medical, surgical, laboratory and x-ray treatment by any of the Physicians of Columbus Children's Healthcare, their assistants, or their designees, as is in their judgment necessary. I further acknowledge that no guarantees have been made to me as to the results of treatment or examination in the clinic. Any tissue removed may be disposed of by Columbus Children's Healthcare in its customary manner. I understand that I have (or the patient has) the right to refuse treatment and that my signature below is not a consent to any non-routine or non-emergency procedure. The physician and/or a member of the nursing staff may ask me to sign a form consenting to special medical or surgical procedures. I also understand this consent shall be considered valid for today's clinic visit and any and all subsequent visits, unless I specifically say otherwise. Patients are encouraged to insist on any additional information necessary to make an informed decision to consent or refuse treatment. I acknowledge that the physicians and certain other practitioners providing services to me may be independent contractors, and are not employees or agents of the clinic.

2. Release of Information: I understand that Columbus Children's Healthcare may furnish from my (or if signing on behalf of the patient, the patient's) medical record requested information or excerpts, to the referring physician, if any and to any insurance company or third-party payer, for the purpose of obtaining payment of the account of the clinic, or any physician for services provided to the patient. The clinic may release my (or if signing on behalf of the patient, the patient's) information from my medical record, including medical, demographic and insurance information, to any physician or other health care provider that I am referred to.

3. Guarantee of Payment: I understand that I am financially responsible for all charges, whether they are covered by my insurance or not. For and in consideration of services rendered to the above patient, I agree to pay in full any amount due for such services, including any reference laboratory tests performed outside of the office.

4. Assignment of Insurance Benefits: I hereby assign to Columbus Children's Healthcare, for services provided by Columbus Children's Healthcare and its employees or others working under contract or arrangement with Columbus Children's Healthcare, all coverage or other benefits available under any government program, any insurance policy or plan, and any other benefit program, and I direct that all benefits be paid directly to Columbus Children's Healthcare. I agree that Columbus Children's Healthcare directly receive benefit payments and discharge the insurer or benefit program to the extent of such payments. Any credit balance resulting from benefit payment or other sources may be applied to any other account owed by me or the undersigned. The benefits assigned include, but are not limited to, all benefits for all medical and hospitalization insurance, accident insurance, disability or loss-of-time insurance, Medicare, Medicaid, and CHAMPUS, benefits payable by alternative delivery systems such as HMOs and PPOs or arising from worker's compensation or occupation disease claims; and proceeds to which I am, or my estate is, entitled because of any judgment, settlement, or other claim or cause of action for damages against any person or organization if I was or am injured. This assignment may not be revoked as to services provided during this clinic visit or course of diagnosis and treatment.

5. Revocation: My consent for routine care shall be ongoing and remain valid unless and until I revoke it, which I may do at any time, verbally or in writing.

6. Financial Agreement: I agree to promptly and fully pay all charges for services and supplies provided by the clinic, physicians, and others providing services in accordance with their regular rates and terms. I hereby personally obligate the patient, and also personally obligate myself if signing as the patient, the spouse of the patient, the parent of a minor patient, or the legal guardian of a patient, for payment of all such charges at the regular rates to the extent not covered by insurance, and agree to pay any charges which, for any reason, are not promptly paid by insurance. I understand that it is my responsibility to obtain any prior approvals required by an insurer, and to take all other steps to qualify for insurance coverage; I will determine whether my insurer requires pre-certification before I receive clinic services. No extension or forbearance, no attempt to obtain payment from insurance or other sources, and no delay or lack of diligence in collecting such charges shall waive or release the personal financial obligations hereunder.

7. Authorization of Communications: I consent to be contacted by regular mail, by e-mail, or by telephone (including a cell phone/wireless number) regarding any matter to my account(s), by Columbus Children's Healthcare or any entity to which Columbus Children's Healthcare assigns my account(s). This includes contact for the purpose of scheduling, telemarketing, debt collection, or other purposes. I consent for Columbus Children's Healthcare to use technology, including automated technology such as auto-dialing or pre-recorded messages, to contact me at the address, e-mail address, or telephone number, including any cell phone/wireless number, I have provided, or any updated or additional contact information I provide at a later time. I agree, subject to state or federal law, to pay all costs, reasonable attorney fees, expenses, delinquent charges, and interest in the event Columbus Children's Healthcare has to take action to collect the same because of my failure to pay in full. This consent applies to all health care providers and agents covered under this agreement. If I discontinue use of any cell phone number provided, I shall promptly notify Columbus Children's Healthcare and hereby indemnify Columbus Children's Healthcare and its agents and independent contractors from any expenses or other loss arising from any failure to notify.

8. Acknowledgement of Notice of Privacy Practices: I was given the Columbus Children's Healthcare Notice of Privacy Practices:

9. Acknowledgement of Financial Policy: I was given the Columbus Children's Healthcare Financial Policy.

THE UNDERSIGNED CERTIFIES THAT HE/SHE HAS READ THE FOREGOING, AND IS THE PATIENT OR IS DULY AUTHORIZED BY OR ON BEHALF OF THE PATIENT, TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS. I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND ANY QUESTIONS I ASKED HAVE BEEN ANSWERED TO MY SATISFACTION. IF SIGNING FOR SOMEONE ELSE, I REPRESENT THAT I HAVE LEGAL AUTHORITY TO DO SO.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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