Medical History and Consent for Treatment
I certify that the above information is accurate, complete and true.
I authorize and any associates, assistants, and other health care providers it may deem necessary, to treat my condition. I understand that no warranty or guarantee has been made of a specific result or cure. I agree to actively participate in my care to maximize its effectiveness.
I give my consent for to retrieve and review my medication history. I understand that this will become part of my medical record.
I acknowledge that I have had the opportunity to review Notice of Privacy Practices, which is displayed for public inspection at its facility and on its website. This Notice describes how my protected health information may be used and disclosed, and how I may access my health records.
I authorize the to release my Protected Health Information (medical records) in accordance with its Notice of Privacy Practices. This includes, but is not limited to, release to my referring physician, primary care physician, and any physician(s) I may be referred to. I also authorize to release any information required in obtaining procedure authorization or the processing of any insurance claims.
I understand that will not release my Protected Health Information to any other party (including family) without my completing a written “Patient Authorization for Use and Disclosure of Protected Health Information” form, available at its facility and on its website.
Please note that our office does not do prior authorizations for prescription medications that are not on your prescription formulary. If your insurance or pharmacist will not fill your prescription as written, you must speak with the pharmacist about this. is unable to know which prescriptions your particular insurance company approves or disallows. Your insurance company can provide this information to you.
prescribes the most medically effective drug for your individual need and cannot speak with each insurance office in regard to their formulary.
In the event that I am asked to provide a urine and/or blood sample, I voluntarily seek laboratory services and hereby consent to provide a urine and/or blood sample as requested. I have the right to refuse specific tests, but understand this may impact my pain management treatment. This agreement can be revoked by me at any time with written notification and is valid until revoked. I hereby assign to Aegis Labs my right to the insurance benefits that may be payable to me for services provided, arising from any policy of insurance, self-insured health plan, Medicare or Medicaid in my name or in my behalf. I further authorize payment of benefits directly to Aegis Labs. I understand that acceptance of insurance assignment does not relieve me from any responsibility concerning payment for laboratory services and that I am financially responsible for all charges whether or not they are covered by my insurance. Payment in full is expected 30 days of being notified of any balance due. Please note that in the event that you fail to make payment when due, this account will be referred to a collection agency for collections. In that event, the contingency fee assessed by the collection agency will be added to the principal and interest due. You will be additionally liable for attorney fees. Both collection agency fees and attorney fees will increase the balance you owe.[/fusion_builder_column][/fusion_builder_row][/fusion_builder_container]