Privacy and Billing Procedures Dr J

Dr. J Express Care’s Privacy and Billing Procedures Authorization and Acknowledgement

These authorizations/acknowledgements cover all services rendered to me, or the patient I am signing for, today and all future dates of service. I understand I may revoke this authorization by informing Dr. J Express Care in writing, but if I do revoke this authorization, it will not affect anything prior to the date the revocation is received by Dr. J Express Care.

 

Acknowledgement of Receipt of Notice of Privacy Practices Authorization to Release Information to Family/Friends or Others

I have received a copy of Dr. J Express Care’s Notice of Privacy Practices. I authorize Dr. J Express Care to release any information regarding my treatment; including lab results, x-rays, and medical records, to the following individuals/entities (Dr. J Express Care may not release information or records to the names individuals/entities unless you identify them here):

Name _______________________ Relationship to Patient ________________________

Name _______________________ Relationship to Patient ________________________

Name _______________________ Relationship to Patient ________________________

Name _______________________ Relationship to Patient ________________________

Dr. J Express Care will use my home phone number and primary address supplied during registration to contact me regarding my treatment; including lab results, x-rays, and medical records. I will ensure this information is up to date at every visit.

 

Authorization to Treat and Bill

I consent to be treated by Dr. J Express Care. If I am not the patient being treated, I am authorized to consent to treatment and billing for the patient identified below. I authorize Dr. J Express Care to bill my medical insurance for the care I receive and to release any information the insurance carrier requires to process this bill. I authorize payment of medical benefits to Dr. J Express Care, or to outside labs as described below, for all services performed and billed by Dr. J Express Care. I understand that I am responsible for all charges for the treatment I receive at Dr. J Express Care. I understand that Dr. J Express Care providers may utilize the Prescription Monitoring Program service at no additional charge to me.

 

As a courtesy, Dr. J Express Care will bill my medical insurance. If I do not provide complete and accurate insurance information to Dr. J Express Care, I understand Dr. J Express Care may not receive payment for my carrier and I will be entirely responsible for my bill. Even after my medical insurance company pays Dr. J Express Care’s bill, I may owe Dr. J Express Care payment for services not covered by my insurance and I agree to pay these promptly to Dr. J Express Care. I understand that Dr. J Express Care may send lab specimens to an outside laboratory. I authorize any lab performing services for me to bill my medical insurance for their services. I understand that my medical insurance may not pay for all services provided by the lab and I agree to pay any remaining balance promptly to any outside lab providing services to me. I understand that Dr. J Express Care is not responsible for payment to outside labs for tests provided to me.

 

To protect my privacy and prevent fraud, I understand that if I cannot provide acceptable photo identification at the time of service, Dr. J Express Care may choose not to bill insurance and may decline credit/debit cards and checks as a form of payment. I understand that if I fail to pay Dr. J Express Care for services provided to me, the balance owed may be sent to collection and I may incur collection fees of up to 25% in addition to the amount owed for services/treatment rendered. I understand that I may contact Dr. J Express Care to work out payment arrangements that may prevent this additional cost.

 

Signature ____________________________________________ Today’s Date _________________

Patient Name _________________________________________ Patient’s Date of Birth _____________

Name of Patient

Representative *_______________________________________ Relationship to Patient* ____________

*(Required if the patient is a minor or if the patient is unable to sign this form.)

Version 10.05.15