I hereby give lifetime authorization for payment of insurance benefits to be made directly to Dr. Machtinger for services rendered. I have fully disclosed all information concerning the insurance/third-party benefits to which I am entitled. I understand that I am financially responsible for all charges Whether or not they are covered by insurance. Understand that if If oil to cancel my appointment with 24 hours notice, I Will be charged a processing fee of a minimum of $25.00. I Understand and accept that if my insurance company has not remitted payment within sixty (60) days of submission of the bill that I will then be billed directly with payment due immediately at that time. In the event of default, I agree to pay all costs of collection and reasonable attorney’s foes. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original
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In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.
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The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of , and request for PHI to the minimum necessary to accomplish the intended purpose. The provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual.
Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly will constitute an adequate record.
Note: Uses and disclosures to TPO may be permitted without prior consent in an emergency
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PRIVATE INSURANCE PLANS
I understand and accept that irrespective of my insurance status I am responsible for the balance of my account for any medical service provided by this Practice. I have read the Financial Policy and have completed the Patient Registration Form. I have had an adequate opportunity to ask questions. I certify that this information is true and correct to the best of my knowledge.
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