Notice of Privacy Practice (HIPPA)
As part of my health care, Tri County Pediatrics originates and maintains paper and/or electronic records describing patients health history, symptoms, examinations, test results, diagnoses, treatment and any plans for future care or treatment. This information serves as:
- A basis for planning patient care and treatment
- A means of communication among the many health professionals who contribute to patient care
- A source of information for applying my diagnosis and surgical/treatment information to my bill
- A means by which a third-party payer can verify that services billed were actually provided
- A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
Consent to Disclosure of Patients Protected Health Information
I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for heath care operations such as quality reviews.
I understand and have been provided with the practice Note of Privacy practice before signing this document.
I understand that this practice has the right to change their privacy practices and that I may obtain any revised notices at the practice.
I understand that I have the right to request a restriction on how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my request, they must follow the restrictions.
I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.
I understand by failing to sign or revoking this consent, the practice may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.
I fully understand and accept the terms of this consent.
Guarantor Recognition of Fiscal Responsibility
I understand that I am responsible at the time services are rendered. I also understand that even though the office, out of courtesy, may verify my benefits, this is not a guarantee of payment. All benefits and eligibility are subject to change without notice. The benefits we verify are only a general summarization and are not intended to be used as an authorization of services provided. In the event my insurance does not cover all charges, I agree to pay the balance due in a timely manner. I am also responsible to notify the office of insurance changes.
I understand Tri County Pediatrics strongly believe in effective communication concerning vaccine benefits and risks. They strive to stay on track with the vaccine schedule and encourage me to follow the time schedule that is given as it is recommended by the AAP and CDC. All vaccines are recorded in patients chart and reported to the Georgia Registry of Immunization to ensure that each patient's vaccination history remains current. No alternative vaccine schedule will be approved/allowed. Parents interested in alternate vaccine schedule may follow up at the Health Department. I understand If I refuse to vaccinate, I will have 90 days to reconsider my decision or my child will be released from the practice.
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.