ADVANCED ORTHOPEDIC & SPORTS MEDICINE CENTER
If yes, please complete employment information:
If you are involved in a lawsuit or have an attorney for your injury your injury insurance may not pay for your treatment. You will be responsible for the full amount. Please speak with the Billing Department before being seen.
I, the undersigned certify that I (or my dependent) have coverage with the insurance listed above and assign payment directly to JEFFREY F. TRAINA, MD all insurance benefits for services rendered. I understand that I will notify JEFFREY F. TRAINA, MD of any changes in my insurance information immediately and that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the staff at ADVANCED ORTHOPEDIC & SPORTS MEDICINE to release any and all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions. I also understand that any incorrect information or false representation of this information may result in either termination of treatment and / or payment of all unpaid balances in full. I also understand that with my insurance coverage there still may be portions that I will be responsible for. All co-pays must be paid at the time of service. Failure on our part to collect co-payments and deductibles from you can be considered fraud.
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.
Thank you for choosing our office. We are committed to be a partner in your medical care. Please understand that the payment of your bill is part of this treatment and care. For your convenience, we have developed a written statement of our billing policies. If you need further information regarding these policies, please ask to speak with our billing department. It is important for you to understand that your health insurance coverage is an agreement between you and your insurance company. The doctor's bill for services rendered is an agreement between you and your doctor. WE do however participate with most but not all insurance companies. If we do participate with your insurance company, all services performed in our office, at the hospital, or nursing homes will be submitted to them for payment unless we receive prior notification of non· covered services. Not all services you receive may be covered by your insurance. You must still pay for these services. Having more than one insurer does not necessarily mean that the services you receive will be covered 100%. We will bill your secondary insurance as a courtesy to you. You are responsible for any balances that remain after all insurances have processed your claim.
All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance card in order to verify proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be personally responsible for this claim. We will submit your claim and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly and it is your responsibility to comply with their request. Please be aware that the balance of the claim is your responsibility whether or not the insurance company pays your claim. If your insurance company does not pay your claim in 60 days, the balance will become your responsibility and billed directly to you.
Our office accepts Visa, MasterCard, AMEX and Discover for your convenience, as well as cash and checks. Returned checks will be subject to a service charge of $35.00. Should we need to bill you for services performed, our office will send you a monthly statement. Any outstanding balances are due within 30 days of the statement.
I have received and agree to the terms of JEFFREY F. TRAINA, MD Financial Policy.
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.
As stated in our privacy policy, "With your permission, your medical information may be released to a family member, guardian or other individuals involved in your care.
By signing this you agree that the below-listed persons may be notified about any situation as it relates to the medical care that you receive. Included but not limited to: insurance issues, test results, and appointment dates and times.
Please list all the people that we may release ANY of your information to. Please be advised that if asked to release ANY information over the phone we have the right to deny the person even if they are listed. We must be able to verify identity.
If this information changes, it is your responsibility to notify us so that they may be removed from this list.
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.
I authorize and request the disclosure of all protected information for the purpose of review and evaluation. I expressly request that the designated record custodian under HIPAA identified above disclose full and complete protected medical information including the following:
All medical records, meaning every page in my record, including but not limited to office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurses notes, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, prescription history, statements, questionnaires/histories, photographs, videos, telephone messages and records.
I understand the information to be released or disclosed may include information relating to sexually transmitted, diseases, acquired immunodeficiency syndrome, or human immunodeficiency virus, and alcohol and drug abuse. I authorize the release or disclosure of this type of information.
This protected health information is disclosed for the following purposes continued medical evaluation and/or treatment
You are authorized to release the above records to the following:
Advanced Orthopedic and Sports Medicine Center
Jeffrey F. Traina, M.D.
800 S. 3rd Street
Leesville, La 71446
Phone: 337-404-4075 | Fax: 337-446-2548
I understand that I have the right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization; the information release in response to this authorization may be re-disclosed to other parties; my treatment or payment for my treatment cannot be conditioned on the signing of this authorization.
Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two (2) years from the date of execution, at which time this authorization shall expire.
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.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Your signature and date below indicates you were given the above noted information sheet on this date.
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.
This acknowledgment is to be filed in patient’s medical record.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Practice is committed 10 maintaining the privacy of your protected health information ("PHI','), which includes information about your heallh condition and Ihe care and Irealment you receive from the Practice. The creation of a record detailing the care and services you receive helps this office to provide you with quality heallh care. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI. The privacy of PHI in patient files will be protected when the files are taken to and from the Practice by placing the files in a box or brief case and kept within the custody of a doctor or employee of the Practice authorized to remove the files from the Practice's office.
The Practice may use and/or disclose your PHI for the purposes of:
This Practice maintains a sign-in log for individuals seeking care and treatment in the office. This sign-in sheet is located in a position where staff can readily see who is seeking care in the office, as well as the individual's location within the Practice's office suite. This information may be seen by and is accessible to, others who are seeking care or services in the Practice's offices.
Amend your PHI as provided by 45 CFR 164.528. To request an amendment, you must submit a written request to tile Practice's Privacy Officer. You must provide a reason that supports your request. The Practice, may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by the Practice (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the Practice, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the Practice's denial, you will have the right to submit a written statement of disagreement.
Receive notice of any breach of confidentiality of your PHI by the Practice.
Complain to the Practice or to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W .. Room 509F, HHH Building, Washington, D.C. 20201,202 619-0257, email: ocrmail@hhs.gov if you believe your privacy rights have been violated. To file a complaint with the Practice, you must contact the Practice's Privacy Officer. All complaints must be in writing.
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.
The Practice may disclose to your family member, other relatives, a close personal friend, or any other person identified by you, your PHI directly relevant to such person's involvement with your cafe or the payment for your care unless you direct the Practice to the contrary. The Practice may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. However, in both cases, the following conditions will apply:
Uses and/or disclosures, other than those described above, will be made only with your written Authorization.
You may revoke your authorization to us at any time; however, your revocation must be in writing.
You may request restrictions on certain use and/or disclosure of your PHI as provided by law. However, the Practice is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Practice's Privacy Officer. In your written request, you must inform the Practice of what information you want to limit. Whether you want to limit the Practice's use or disclosure, or both, and to whom you want the limits to apply. If the Practice agrees to your request, the Practice will comply with your request unless the information is needed in order to provide you with emergency treatment.
Inspect and obtain a copy of your PHI as provided by 45 CFR 164.524. To inspect and copy your PHI, you are requested to submit a written request to the Practice's Privacy Officer. The Practice can charge you a fee for the cost of copying, mailing or other supplies associated with your request.a
Receive confidential communications or PHI by alternative means or at alternative locations. You must make your request in writing to the Practice's Privacy Officer. The Practice will accommodate all reasonable requests.
Prohibit report of any test, examination or treatment to your health plan or anyone else for which you pay in cash or by credit card.
Receive an accounting of disclosures of your PHI as provided by 45 CFR 164.528. The request should indicate in what form you want the list (such as a paper or electronic copy)
Receive a paper copy of this Privacy Notice from the Practice upon request to the Practice's Privacy Officer.
Request copies of your PHI in electronic format if this office maintains your records in that format.
Your information will be encrypted.