If you are unable to complete the forms above, you may print this page out, and sign/date each section.
Privacy Policy HIPPA
Federal regulations require health practices to keep your medical information protected. Protected Health Information (PHI), is shared with affiliate healthcare practitioners, as well as healthcare providers that participate in your care, your insurance company to obtain payment for health benefits claims filed, or management of health issues relating to your health. All associates assisting with our internal operations are required to maintain confidentiality of protect health information. All other releases of information have to be specifically authorized by you. If you ask us to account for these release of information, we will provide that to you. You may also request and receive a copy of your medical record and ask questions about its content. We will keep your record as long as you are a patient of the practice and seven years after your last visit. You will be given a form to sign which shows the details of to whom you wish to have your PHI (Protected Health Information) released.
I acknowledge that I have been informed about the privacy of my medical record.
General Consent for Treatment
We appreciate you entrusting your or a family members health care to our practice. However, we need your permission for our clinicians to examine you, provide treatments, and perform diagnostic studies as necessary. If more invasive procedures are deemed necessary, the risks and benefits of those invasive treatments will be explained to you.
I give general consent to be treated practitioner of Cher Aymond MD
Financial Policy/Assignment of Benefits
As a courtesy, the practice will accept assignment for some commercial insurance programs and Medicare. We will file claims with your primary and secondary health insurance providers for you. It is your responsibility to ensure you have provided us with correct health insurance information. However, health insurance is a contract between you and your health insurance provider. Therefore, we ask that you acknowledge your responsibility for payments for any services rendered through our practice. If health insurance(s) deny coverage, disallow a service, or otherwise does not pay a claim, you are responsible for fees. In addition, if fees for our services are not paid, we may turn the account over to a collection agency. If an account is turned over for collection, their fees, attorney's fees, and court costs will be added to the account balance.
Also, your insurance company may ask us to provide information concerning your treatment before they will pay for the services.
All insurance Accounts must be paid in full within 90 days regardless of pending payment . PAYMENT IN FULL IS REQUIRED AT TIME OF VISIT .
Any credit balance over$5 remaining after insurance payment will be refunded. less $5 will be posted to the patient account for future use.
If your visit is related to Altercation or motor Vehicle accident or work related, left let office know before signing in.
I acknowledge responsibility for payment of fees for services provided by the practice and authorized the practice to release any medical information, if necessary, to my insurance company.
