Patient Consent Form

. Consent And Understanding

This consent is required by the Health Insurance Portability & Accountability Act (HIPAA) of 2004 to inform you of your rights to privacy with respects to your Health care information.

Consent for Care:
I, with my signature authorize NP Health Clinic and any employee working under the direction of the Nurse Practitioner to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services and supplies related to my health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment of review of physical or mental status/function of the body and sale and dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.

Financial Policy:
We appreciate you choosing us for your health care. We will adhere to the following financial policy in order to consistently deliver high quality care and services. The patient/responsible party assumes responsibility to ensure that the financial obligation is fulfilled for the health care services received.

I understand that I am responsible for all payments or charges incurred from services received.

I understand that my contract with my insurance entity may or may not cover some services. All insurance policies are not the same. They vary by employer group. Practitioners in NP Health Clinic Inc is not responsible or able to know every policy available. It is my responsibility to verify applicable coverage prior to receiving the services. For example, Not all health care plan include screenings as a benefit. If I seek care outside of the contract terms, I am aware that I may be responsible for all charges that are incurred.

Practitioners in NP Health Clinic Inc. is a Nurse Practitioner owned and operated business

Thank you for your understanding and cooperation with this policy. It is out privilege to provide your medical care.

I have read and understood the Consents and Financial Policy stated above and agree to accept full responsibility as described above.