Please check only one from each section.
Pharmacy phone number is required to expedite refill / new prescriptions.
I voluntarily request Deirdre McMullen M.D., and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing is recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I authorize Rocky Creek Family Medicine, PLLC to release any medical and social information acquired during the course of my examination and/or treatment, for the purpose of filing for insurance and other financial coverage, and to provide required information to other medical professionals and facilities for my continuing diagnosis and treatment. I hereby authorize payment of medical benefits directly to Rocky Creek Family Medicine, PLLC. I understand that I am financially responsible for charges not covered by this assignment of benefits, and should the account be referred for collection, I agree to pay reasonable collection and/or attorney's fees.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Purpose: The MHiE is a health information exchange network developed by Memorial Hermann Healthcare System. Exchange Members include hospitals, physicians and other healthcare providers. Exchange Members are able to share electronically medical and other individually identifiable health information about patients for treatment, payment and healthcare operation purposes. We are an Exchange Member of the MHiE and we seek your permission to share your health information with other Exchange Members via the MHiE. By executing this form, you consent to our use and electronic disclosure of your health information to other MHiE Exchange Members for treatment, payment, and healthcare operation purposes. We will not deny you treatment or care if you decline to sign this Consent, but we will not be able to electronically share your health information with your healthcare providers that participate in the MHiE as Exchange Members if you do not sign this Consent.
Instructions: If you agree to allow us to disclose your health information with other MHiE Exchange Members please complete the relevant portions of and sign this Consent.
hereby consent to the disclosure of my medical, health and encounter information by any and all Memorial Hermann Healthcare System providers (collectively the "Provider") to other participating providers in the MHiE (Exchange Members) who may request such information for treatment, payment or healthcare operation purposes. I understand the information to be disclosed includes medical and billing records used to make decisions about me.
I HEREBY SPECIFICALLY AUTHORIZE PROVIDER TO RELEASE ALL TYPES AND CATEGORIES OF PROTECTED HEALTH INFORMATION TO OTHER HEALTHCARE PROVIDERS THAT PARTICIPATE IN THE MHiE FOR TREATMENT, PAYMENT AND HEALTHCARE OPERATION PURPOSES, [INCLUDING BUT NOT LIMITED TO, YOUR ALCOHOL AND TREATMENT RECORDS, YOUR DRUG ABUSE TREATMENT RECORDS, YOUR MENTAL HEALTH RECORDS, AND YOUR HIV/ACQUIRED IMMUNE DEFICIENCY SYNDROME RECORDS, AS APPLICABLE].
No Conditions: This Consent is voluntary. We will not condition your treatment on receiving this Consent. HOWEVER, IF YOU DO NOT SIGN [AND INITIAL] THIS CONSENT, WHERE REQUIRED, YOU CANNOT PARTICIPATE IN THE MHiE.
Effect of Granting this Consent: This Consent permits all MHiE Exchange Members to access your health information. Exchange Members of the MHiE are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
This Consent will remain in effect until you revoke it. You may revoke this Consent at any time by completing the MHiE notice of revocation. The MHiE notice of revocation is available by calling 713-456-MHiE (6443). Revocation of this Consent will not affect any action we took in reliance on this Consent before we received your notice of revocation. Revocation of this Consent will also have no effect on your personal health information made available to Exchange Members during the timeframe in which your Consent was active.
I have had full opportunity to read and consider the contents of this Consent. I understand that, by signing this Consent, I am confirming my consent and authorization of the use and/or disclosure of my personal health information, as described herein.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
If this Consent is signed by a personal representative on behalf of the individual, complete the following:
Include this Consent in the individual's records.
Thank you for choosing us as your health care provider. We are committed to your satisfaction. Please assist us in meeting your expectations by reviewing the Financial Policy below.
Forms: You will be asked to complete a registration form which will include your home address, telephone number, social security number as well as the address and telephone number of your insurance company, if applicable. Insurance company information can generally be obtained from a card provided to the company's insured member, and we prefer to make a copy and scan of the card for our records. We also request a copy of your driver's license or other picture identification to include in your record.
Forms of Payment: For your convenience, we accept cash and checks, as well as many credit and debit cards. We must have a copy of your driver's license to accept checks.
Office Visits: All office charges are payable at the time the service is rendered. If you desire, we will provide you with a copy of the superbill documenting the charges and receipts for your visit, which you may use to file for reimbursement with your insurance carrier.
Financial Responsibility for Minors: Unless prior arrangements have been made, charges for a minor child seen in the office will be the responsiblity of the adult accompanying the minor child.
Managed Care Plans: We are contracted with many managed care plans. We will file your insurance in accordance with our agreement with the plan. Any copayment or deductible for which you are responsible must be paid at the time of service.
Although we can assist you in many ways, it is your responsibility to be familiar with the coverage provided by your insurance plan, particularly with respect to preventive care, immunizations, the authorization of any procedures and your primary care physician. Please let us know when you call to make an appointment of any changes in your insurance coverage or plan. It will be your responsibility to make payment for any services not covered by your insurance company. If benefits and eligibility cannot be verified prior to service, you will be required to pay for services in full. Any charges denied by your insurance carrier will be your responsibility.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
You may refuse to sign this acknowledgement & authorization. In refusing, we may not be allowed to process your insurance claims.
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Please list any other parties who can have access to your health information: (This includes step parents, grandparents and any care takers who can have access to this patient's records):
In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.
Thank you for choosing our care team for your medical care. We appreciate the trust and confidence you have placed in us. Our goal is to provide YOU with high quality, personal medical care, which is responsive to your individual needs and values. In order for this goal to be achievable, it is important that we (the Physician and the Patient and/or the Patient's caregiver) each commit to satisfying certain responsibilities, as follows:
Please take the time to carefully read and understand each of our respective responsibilities. To show that you accept and agree with them, please sign your name below. Thank you once again!
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.