Acknowledgement of Receipt of Notice of Privacy Practices for Protected Health Information (HIPAA): I, the undersigned patient, or personal representative of the patient named below, acknowledge that I have read and been offered a copy of Jefferson County Health Department’s current Notice of Privacy Practices for Protected Health Information on the date set forth below. [45 CFR164]
Consent to Medical Care: I request and consent to the medical care and diagnostic treatment procedures as determined necessary by my physician(s) or his/her assistants. I acknowledge the care I receive while in this facility is under the direction of my physician(s I understand the benefits and risks and hereby consent to vaccines, evaluation, testing, and treatment by my Jefferson County Health Department physician and his/her designee.
Payment for Medical and Related Care: I agree to pay the facility’s set and established charges incurred for the care I receive as ordered by my physician(s) at this facility, including separate charges by independent contractors (such as labs I guarantee full payment of all charges unless restricted by Medicare or Medicaid.
Assignment of Benefits: I hereby assign all of my rights and benefits under my existing policies of insurance providing coverage and payment for any and all expense incurred as a result of services and treatments rendered by the facility, affiliated physicians, and/or other independent contractors, and authorize direct payment to these parties for such services and treatment. I understand that most health insurance policies, including Medicare and Medicaid, are secondary payers to any existing liability policies, no-fault insurance, workers compensation or any other sources of payment that may or will cover expenses incurred for services and treatment.
Communication Concerning Services and Debt Collection: I authorize this facility to communicate with me for any reason related to the provision of services, including collection of amounts owed for services, using text messaging services, an automated telephone dialing system or prerecorded voice at the telephone number(s) I provided, including a telephone number assigned by a cellular telephone service or any service for which I am charged for the call. In addition, I consent to and agree that any calls between this facility and I may be monitored or recorded for any purpose. If debt collection becomes necessary, I also authorize this facility, including any collection agency or debt collector hired by this facility to check my credit and employement history, obtain a copy of my consumer report and obtain personal information from any consumer reporting agency. In the event your account goes to an outside collection agency we will add 28% collection fee to any outstanding balance due.
Payment for Minors: If a minor is brought in for services by someone other than the parent, custodial parent, legal guardian, etc, the charges are to be paid at the time of service by the person bringing the child in. In the case of non-custodial parent having responsibility for medical bills, the person bringing the child in must pay at the time of service and make their own arrangements with the responsible party for reimbursement. I assume responsibility for payment of charges not covered by my insurance, unless I am a minor seeking confidential services.
Acknowledgement and Certification: By signing this form, I certify that I am the patient or the patient's legal representative, I have read this Conditions and Treatment Form, I was given the opportunity to ask questions and I understand and accept all terms herein.