AGREEMENT TO PAY: In consideration of the services rendered and to be rendered by Northeast Internal Medicine to the below captioned patient. l (we) agree to pay Northeast Internal Medicine for all services and charges as are ordered by the attending physician in accordance with the terms and financial policies of Northeast Internal Medicine. We further agree and guarantee that in the event the account is not paid in accordance with the financial arrangements made on the account, to pay any reasonable attorney's fees if this account is placed in the hands of any attorney or collection agency. Detailed financial policies available by request.
AUTHORIZATlON TO PAY INSURANCE BENEFITS: I hereby authorize Northeast Internal Medicine, M.D. or Practitioner to furnish information to my insurance carriers concerning my illness or treatments. I hereby authorize the payment to be paid directly to Northeast Internal Medicine and my attending Physician or Practitioner. All such payments shall constitute a discharge in full to the insurance company to the extent of the benefits paid. I understand I am financially responsible to Northeast Internal Medicine for charges not covered by the authorization.
PATIENTS WITH NO lNSURANCE COVERAGE: I understand that I am financially responsible to Northeast Internal
Medicine for the health services provided to the patient below at time of service unless other arrangements have been made.
CONSENT TO TREATMENT: I hereby voluntarily consent to the provision of all medical care, including diagnostic and treatment procedures, judged necessary by my physician of his designee(s). I acknowledge that no guarantees have been made to me as to the result of such treatment. In addition to all consents given elsewhere in the document, I specifically consent to medical procedures and tests necessarily performed upon me to aid and assist in the diagnosis and treatment of my child. These tests may include tests for the presence or absence of alcohol and controlled
substances.
RELEASE OF MEDICAL lNFORMATlON: I hereby authorize Northeast Internal Medicine and all persons involved with
my care to release information from my medical records to any person, corporation or agency which is legally responsible, for processing and paying all or any part of Northeast Internal Medicine's charges and/or professional fees. I further authorize Northeast Internal Medicine and all physicians involved in my care to release information from my medical records to any physician or health care facility to which I may be transferred for further medical care.
Consent to Wireless Telephone calls: If at any time I provide a cell phone number at which I may be contacted, I consent to receive calls or text messages, including but not limited to communications regarding billing and payment for services. Calls and text messages include but are not limited to pre-recorded messages, artificial voice messages, automatic telephone dialing devices or other computer assisted technology, or by electronic mail, text messaging or by any other form of electronic communication from the office, affiliates, contractors, servicers, clinical providers, attorneys or its agents including co llection agencies.
Consent to email usage: If at any time I provide my email address at which I may be contacted, I consent to receiving
communications regarding billing and payment for items and services at that email address from the office, affiliates, contractors, servicers, clinical providers, attorneys or it agents including collection agencies.
Minor Patients: All minors must be accompan ied by an adult for any non-emergency treatment.
Failure to provide 24-hour notice of cancellation of an appointment can result in a $75 charge. This cannot be billed through insurance and will be the patient's responsibility.
DISCLOSURE OF PROTECTED HEALTH INFORMATION
Under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended, patients have the right to agree, restrict or object to providing Protected Health information (PHI) to family members, friends and/or other person identified as involved in the patient's care or payment for the patient's health care. To comply with the regulations, as outline in Triad HIPAA Privacy Policy 007, documentation of the patient's wishes must be present in the medical record.
Unless you object, PHI can be disclosed to those individals listed below. Additionally, you authorize our staff to update this list per your direction.
