Please fill the sections carefully and ensure that all sections are filled. .Please ensure that there are no errors made in filling the form, as this could lead to non payment by insurance companies.
CONSENT FOR CARE
I hereby give my consent for treatment at Germantown Pediatric and Family Medicine .
I hereby authorize payment to Germantown Pediatrics and Family Medicine for services rendered to me or my dependents. I hereby authorize release of information necessary to expedite the claim process.
LIFETIME AUTHORIZATION TO FILE MEDICARE
I request the payment of authorized Medicare benefits to be made either to me or on my behalf to Germantown Pediatrics and Family Medicine for services furnished at the clinic. I also authorize any holder of medical information about me to release to the Center for Medicare/Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.
When scheduling an appointment, we will make every attempt to verify your insurance and eligibility prior to checking in. Your insurance policy is a contract between you and your insurance company
It is your responsibility to notify us of any changes to your insurance.
We need to see your insurance card and ID at every visit.
You are responsible for verifying your insurance coverage, which includes, but is not limited to co-insurance, copayments, deductibles, and verification of what is covered ( in house labs, preventive care visits, etc). You are responsible for any payments that are not covered by your insurance or that your insurance assigns as your responsibility.
Germantown Pediatrics and Family Medicine will bill my insurance carrier based on the information provided above. I am responsible for I agree to pay any outstanding charges should be account be turned over to an outside collection agency. Germantown Pediatrics and Family Medicine will bill my insurance carrier. However, I understand and agree that I am responsible for payment of all charges for services provided, regardless of any insurance coverage(s).
RETURNED CHECK FEE
We assign a fee of $50 for any returned checks, and will not allow you to write any future checks.
NO-SHOW/LATE CANCELLATION POLICY
Notice of Privacy Practices for Protected Health Information (PHI)
Germantown Pediatric and Family Medicine LLC
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY!
Effective date: January 2021
The Practice of Germantown Pediatric and Family Medicine is required by applicable federal and state laws to maintain the privacy of your health information. Protected health information (PHI) is the information we create and maintain in the course of providing our services to you. Such information may include documentation of your symptoms, examination and test results, diagnoses and treatment protocols. It also may include billing documents for those services. We are permitted by federal privacy law (the Health Insurance Portability & Accountability Act of 1996 (HIPAA), to use and disclose your PHI, without your written authorization, for purposes of treatment, payment, and health care operations. Your Health Information can be used for payment purposes, for treatment purposes, and for health care operation purposes.
Your Health Information Rights
The health and billing records we maintain are the physical property of the Practice. The information in them, however, belongs to you. You have a right to:
The Practice is required to:
We reserve the right to amend, change, or eliminate provisions of our privacy practices and to enact new provisions regarding the PHI we maintain about you. If our information practices change, we will amend our Notice. You are entitled to receive a copy of the revised Notice upon request by phone or by visiting our website or Practice.
Other Uses and Disclosures of your PHI
As Required by Law
Law Enforcement and Correctional Institutions.
Health Oversight Federal law may require us to release your PHI to appropriate health oversight agencies .
Judicial/Administrative Proceedings -We may disclose your PHI with your authorization, or as directed by a proper court order.
For Specialized Governmental Functions or Serious Threat
Coroners, Medical Examiners, and Funeral Directors
Other uses and disclosures of your PHI not described in this Notice will only be made with your authorization, unless otherwise permitted or required by law.
To Request Information, Exercise a Patient Right, or File a Complaint
If you have questions, would like additional information, want to exercise a Patient Right described above, or believe your (or someone else’s) privacy rights have been violated, you may contact the Practice’s Privacy Officer at 901-854-5455, or in writing to us at our practice address.
Please note that all complaints must be submitted in writing to the Privacy Officer at the above address. You may also file a complaint with the Secretary of Health and Human Services (HHS), Office for Civil Rights (OCR). Your complaint must be filed in writing, either on paper or electronically, by mail, fax, or e-mail. The address for the Colorado regional office is: Office for Civil Rights, U.S. Department of Health and Human Services, 999 18th Street, Suite 417, Denver, CO 80202; or call (800) 368-1019. More information regarding the steps to file a complaint can be found at: www.hhs.gov/ocr/privacy/hipaa/complaints.
Your information will be encrypted.