RESPONSIBLE and/or INSURANCE PARTY
For patients under 18 and under we need information of a Parent or Legal Guardian, if not listed above
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Contact Person: Priscilla Goff Telephone: 276-466-2028 Fax: 276-466-1629 E-mail: email@example.com Address: 1740 Euclid Ave Bristol, Virginia 24201 Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
Allows us to discuss treatment or finances with parents, spouses, secretaries etc. as you designate. I agree that the office of Drs Seaver and Pittman can discuss treatment, arrange appointments, discuss fees, and make financial arrangements.
PRESCRIPTION MEDICATION & CONTROLLED SUBSTANCE POLICY
The office of Drs. Seaver and Pittman has developed this mutual agreement to pertain to the treatment of my medical conditions. I understand that the goal of treatment is to improve my functional ability, and in doing so, that sometimes requires narcotics and/or sedatives. These medications sometimes lead to abuse and dependency, though if used correctly, can be very effective. By checking and signing this document in the appropriate areas below, I understand my responsibility and agree to uphold this agreement.
Our office is pleased to accept your insurance assignment. We offer this service as a courtesy to our patients. However, it must be clearly understood that the "contract" is between the patient and the insurance company, the account thereby being the responsibility of the patient for any amount not paid by the insurance company. Following is a statement of our policy governing insurance claims. The patient will pay the co-payment (the amount estimated as not covered by the insurance company) at the time services are rendered. After we receive payment from your insurance company, any difference will be billed to you. We expect payment within 10 days after receipt of your statement.
To reduce our administrative costs and keep our fees to you as low as possible, we ask that you pay your co-payment at the time you receive treatment. Please indicate below the method of payment you intend to use to pay for your dental treatment, including your co-payment.
SLEEP APNEA CONSULTATION QUESTIONS
CANCELLATIONS & CONFIRMING APPOINTMENTS POLICY
Our desire is to provide every patient with the treatment they need, along with the special attention they deserve. We do not overbook patient appointments. However, we will DOUBLE BOOK any unconfirmed appointment. As a courtesy to our patients, we call 2 days prior to your appointment to remind you of your appointment and answer any additional questions you might have about your appointment. If we are unable to reach you one business day before your appointment by 2PM on a Monday - Thursday or 11AM on a Friday, it is considered an unconfirmed appointment and will be taken off our schedule. Please insure you have provided us with the phone number(s) where we can best reach you or leave you a message during daytime hours. If you know you will be unable to keep your appointment, please call us as soon as possible.
So that we can accommodate all our patients’ needs, we ask that you provide us 24 hours notification if you are unable to keep a scheduled appointment.
For those patients who are unable to provide us 24 hours notification, we do have a broken appointment policy whereby you may be charged a fee of $50.00. We understand that circumstances do arise that are beyond your control. We do waive this fee on a case-by-case basis. If you break three appointments within a year, we will no longer be able to see you in our office.
Due to federal regulations, we are not allowed to charge or collect a broken appointment fee from Medicaid patients. Medicaid broken appointments are reported to the Virginia Medicaid System. Once a Medicaid patient does not give us a 24 hour notification of cancellation and breaks 3 appointments in our practice within a 1 year period, they will be terminated/fired from this practice and can no longer be seen. We understand that circumstances do arise that are beyond your control. The decision to terminate/fire a patient will be determined on a case-by-case basis and the patient will be notified in writing.
Patients who consistently break appointments after having confirmed their appointment may be asked to pay a Reservation Fee before an appointment is rescheduled. Reservation Fees will be applied to your appointment.
In consideration of professional services performed by Dr. Tyler L. Pittman, Dr. Michael C. Cagle, Dr. Trevor Lawson, and Dr. Amelia Dinwiddie, the undersigned hereby accepts total and absolute responsibility for all costs incurred as a result of such treatment and services not covered by any acceptable insurance. In the event of default in the payment of any amount due, after thirty days, the undersigned agrees to pay a services charge in an amount not exceeding 1.8% per month on this account. Further in the event this account is referred to an attorney or collection agency, the undersigned agrees to pay reasonable attorney fees, but in no case less than $100.00, or collections fees and court costs as permitted by laws governing these transactions.
I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures (such as X-rays + fluoride treatment) as may be necessary for proper dental diagnosis and care. The information on this page and the medical history are correct to the best of my knowledge.
I have read and understand the above stated policies and completed this questionnaire accurately and completely.