New Patient Registration

Please correct the errors described below.

Responsible Party (if younger than 18 years of age)

Authorization/Waiver of Benefits

I hereby authorize the release of any information necessary to complete and process my insurance claims. I understand that it is my responsibility to obtain all necessary referral from my PCP prior to my visit. If services are denied due to lack of referral, I am responsible for payment in full. I also understand that I am responsible for payment of my account in full or for the portion not covered by my insurance. Finally, I understand that I will be responsible for 100% of all cosmetic charges incurred in this office.

Notice of Privacy Practices

**This Notice of Privacy Practices outlines how your personal medical information may be used and disclosed and you can access this information.

If you have any questions about this notice, please contact our office at 573-803-3331.

OUR OBLIGATIONS:

-Maintain the privacy of protected health information

-Give you this notice of our legal duties and privacy practices regarding personal health information

The following describes the ways we may use and disclose health information that identifies you (“Protected Health Information” or “PHI”). Except for the purposes described below, we will use and disclose Protected Health Information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer.

We may use and disclose PHI for your treatment and to provide you with treatment-related health care services. For example, we may disclose PHI to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

We may use and disclose PHI so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.

We may use and disclose PHI for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

We may use and disclose PHI to contact you to remind you that you have an appointment with us. We also may use and disclose PHI to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

We may use and disclose PHI to you via email or text message. If you initiate an email to us, you agree we may communicate to you via email, including communications disclosing your Health Information. You acknowledge that such email is plain-text and not encrypted or secure. You acknowledge we may communicate to you via text message if you have provided us with your mobile number and that such text messages are not encrypted or secure.

To respond to a comment or question from you in a public or online forum. If you initiate a comment or question to us in a public forum, such as an event or seminar, or an online forum including social media websites, online review websites, blogs or other internet forums, you agree we may use and disclose your PHI in responding to your questions or comments.

When appropriate, we may share PHI with a person who is involved in your medical care (if you have designated so) or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

We will disclose PHI when required to do so by international, federal, state or local law.

ACKNOWLEDGEMENT OF RECEIPT

By signing this form, you acknowledge receipt of and agree to the Notice of Privacy Practices of Alliance Health. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information.

I acknowledge receipt of and agree to the Notice of Privacy Practices of Alliance Health.

Financial Obligation Agreement

I understand and agree that I will be financially responsible for any and all charges for services not paid by my insurance for my medical visits. This includes any medical service, visit, preventative exam or physical exam, lab test, imaging test, pathology test, and any other screening service or diagnostic testing ordered by the physician or the physician’s staff.

I understand and agree it is my responsibility and not the responsibility of the physician or the physicians’ staff to know if my insurance will pay for any medical service I receive.

I understand and agree it is my responsibility to know if my insurance has any deductible, co-payment, coinsurance, out-of-network amounts, usual and customary limit, or any other type of benefit limitation for the medical services I receive. If I have an insurance plan with a deductible or co-insurance responsibility, I agree to pay this fee at the time of my visit. After receiving my billing statement, I agree to pay for my patient-responsible amount that was not fully covered by my insurance. I understand and agree it is my responsibility to know if the physician or provider I am seeing is a contracted in-network provider recognized by my insurance company or plan. If the physician or provider I am seeing is not recognized by my insurance company or plan, it may result in claims being denied or higher out of pocket expense to me. I understand this and agree to be financially responsible for all charges. I understand and agree it is my responsibility to know if a referral is needed to see a specialist. I understand this and agree to be financially responsible and make full payment.

I understand and agree that if I am unable to keep my appointment, then I must notify the office at least 24 hours in advance of my appointment time. This is necessary to accommodate another patient waiting for an appointment time that would otherwise not be available. I will be reminded of my appointment by phone 24-48 hours in advance. I will respond and notify the office by phone if I can not keep the appointment.

Your information will be encrypted.

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