Consent for Medical Treatment:
I consent to diagnostic evaluations and treatments as deemed necessary and appropriate by clinical providers of NeuroPsych Program. I understand the purpose of this/these visit(s).
I understand that NeuroPsych Program offers educational experience to residents, medical students, professional healthcare entities students, and others with specific health-related learning needs. I authorize these residents/students to observe my care and, if appropriate, participate in that care. I understand that these residents and students are not employees or agents of NeuroPsych Program. The acts or omissions of such residents and students are the responsibility of their sponsoring institutions, not of NeuroPsych Program.
NeuroPsych Program assumes no liability for the loss of money or damage to articles of value.
Consent for Billing and Medical Information Release for Billing:
As a courtesy to you, we will bill all primary and secondary insurance claims. Please advise us if you do not want us to file your insurance claims for you. YOUR INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY.
Medicare Patients with a Secondary Insurance:
I certify that the information given by me in applying for payment under Title XVIII of the Social Security Acts is correct. I request that payment of authorized benefits be made.
I assign the benefits payable for physician’s services to the NeuroPsych Program.
I authorize any holder of medical and/or other information about me to be release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim.
I understand that NeuroPsych Program cannot assure me of Medicare payment for any service, nor are they responsible if Medicare disallows a lab or x-ray charge incurred from a visit to NeuroPsych Program. I understand that I will be billed from NeuroPsych Program if
1) The charges incurred have been applied to my Medicare deductible
2) If I do not have a second insurance, and/or
3) If Medicare and my second insurance do not cover the total charges incurred at my visits to the Clinic.
I authorized NeuroPsych Program to release to my insurance provider(s) any medical information relating services rendered for insurance processing, quality assurance, or utilization review. The information to be released for insurance processing will be diagnosis and/or documentation of service provided for which charges are to be made. The information to be released may include psychiatric, developmental disability, alcohol and/or drug abuse information, HIV testing, and AIDS or AIDS related disease diagnosis unless specified by the following:
I understand that this authorization for releasing information will be effective for one year from the date of my signature unless otherwise stated below or revoked through written notice to the Medical Records Department of NeuroPsych Program. Alternative date if not one year: _________.
Assignment of Benefits:
I hereby authorize payment directly to NeuroPsych Program of the medical expense benefits otherwise payable to me by the Insurance Provider. I understand that I am financially responsible to the Clinic for charges not covered by Insurance.
Receipt of Privacy Notice:
I acknowledge receipt of NeuroPsych Program’s Notice of Privacy Practices.
By signing below, I hereby consent to the above agreement.