Responsible Party (If Other Than Patient)
TriStar Summit Medical Center
5653 First Boulevard, Suit 731
Hermitage, TN 37076
This form is not required for injuries occuring on or after July 1, 2014
THIS MEDICAL AUTHORIZATION FORM ONLY PERMITS THE EMPLOYER OR THE BUREAU OF WORKERS COMPENSATION TO OBTAIN MEDICAL INFORMATION THROUGH ORAL OR WRITTEN COMMUNICATION INCLUDING, BUT NOT LIMITED TO, CHARTS, FILES, RECORDS, AND REPORTS IN THE POSSESSION OF A MEDICAL PROVIDER AUTHORIZED BY THE EMPLOYER PURSUANT TO T.C.A. 50-5-204 AND A MEDICAL PROVIDER AUTHORIZED BY THE EMPLOYER FOR THE EMPLOYEE'E TREATMENT.
I having filed a claim for workers' compensation benefits, do hereby authorize Pinnacle Surgical Orthopedics and Pinnacle Physical Therapy and Rehabilitaion to furnish to my employer or my employer's represantative, and / or the Bureau of Workers' Compensation any information or written material resonably related to my work-related injury of the following Date for which I am claiming compensation. I further authorise the release of the same information to me or my attorney. The aithorisation includes, but is not restricted to, right to review and obtain copies of all records, x-rays, x-ray reports, medical charts, prescription, diagnoses, opinions and course of treatment.
A photocopy of the authorisation may be accepted in lieu of the original.
Check all surgeries You have had
General Consent For Treatment
As the patient, you have the right to be informed about your condition and the recommended surgical, medical, or diagnostic precedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify appropriate treatment and/or procedure for any identified condition(s).
I request and authorize medical care as my provider, his assistant or designees (Collectively called "the providers") may deem necessary or advisable. This care may include, but is not limited to routine diagnostics, radiology ane laboratory procedures, administation of routine drugs, biological and other thrapeutics and routine medical and nursing care. I authorise my provider(s) to perform other additional or extended services in emergency situations if it may be necessary and that other personnel render care and services to me (the patient) according to the provider(s) instructions.
I understand that i have the right and the opportunity to discuss alternative plans of treatment with my provider and to ask and have answered to my satisfaction any questions or concerns.
In the event that a healthcare workeris exposed to my blood or bodily fluid in a way transmit HIV (human immunodeficiency virus), hepatitis B virus or hepatites C. I concent to the testing of my blood and or bodily fluids for these infections and the reporting of my test results to the healthcare worker who has been exposed.(Initial)
I HAVE READ OR HAD READ TO ME AND FULLY UNDERSTAND THIS CONSENT; I HAVE HAD THE OPPOTUNITY TO ASK QUESTIONS AND HAD THESE QUESTIONS AND HAD THESE QUESTIONS ADDRESSED.
This is an agreement between AdvancedHEALTH, as creditor, and the patient/Debtor named on this form and indicated by patient/debtor signature below.
In this agreement the words "You", "Your" and "Yours" mean the patient/Debtor. The word "account" means the account that has been established in your name to which charges are made and payments credited. The Words "we", us and "our" refer to AdvancedHealth. By executing this agreement, you are agreeing to pay for all services that are rendered.
Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect. A copy of your signed financial agreement will be provided to you.
: A statement of account will be provided to you if insurance has paid leaving a patient portion, denied or no reponse is received. Due to the type of service we provide, you may receive billing from more than one practice, otherwise known as split billing. The balance on your statement is due and payable within 30 days of receipt unless other arrangements are made with our billing department. The statement will be sent to the address provided at the time of service. In the event your mailing address changes after your service date and your account has not been paid in full, you are required to notify out billing office of this change by calling 615.851.6033 ext 2067. In case of divorse of separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, tthe parent authorizing treatment for a child at time of service will be the parent reponsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, court documentation is requires the other parent to pay all or part of the treatment costs, court documentation is required for any guarantor address changes, otherwise, it is the authorising / custodial parent's responsibility to collect from the other parent. Any account with a credit balance or less than <$5.00> will not berefunded without specific request from the patient / debtor.
We review past due accounts frequently and at every statement cycle. Your communication and involvement to ensure your balance is paid timely is important to us. It is impressive that you maintain communication and fullfill your financial agreement and arrangements to keep your account active and in good standing. If your account becomes sixty(60) days past due, further steps to collect this debt may be taken. If we have to refer your account to a collection agency, you agree to pay all of the collection costs, which are incurred. If we have to refer collection of the balance to a lawer, you agree to pay all lawyer fees which we incur plus all court cost. In case of suit, you agree the venue shall be Davidson County, Tennessee. In addition, we reserve the right to deny future non emergency treatment for any and all debtor-related unpaid account balances.
WAIVER OF CONFIDENTIALITY:
You understand if your account is submitted to an attorney or collection agency. If we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.
You will be required to request in writing or sign medical authorisation form for the release of your medical records to any organisation or physician. We change a $20 flat rate for 1.5 pages plus .50 per additional page and postage.
PAYMENT OPTIONS: Per our contracted agreement with your insurance carrier, we are required to collect your co-payment on the day of service. If you do not have insurance, you are required to pay for treatment at the time of service unless other all copays plus estimated coinsurance and deductibles at the time of service.
We accept the following: Cash Check Credit Card (Visa, MasterCard, Discover, American Express)
A twenty-five dollar ($25.00) returned check fee will be assessed to the patient account per incident.
For convenience, payments may be made online at www.ePayItOnline.com. To utilize this service you will need your account number, access code, and code ID. This informationcan be found on the patient statement you will recieve reflacting your balance. Patients who no-show may be subject to a no-snow fee.
PENDING APPROVALS FOR SERVICES: In the event we are unable to obtain approval for services and you wish to proceed, we will not bill your insurance. Services will be reduced to the in-network inurance allowable amount and will apply to the patient's responsibility.
I understand that under the Health Insurance Portability & Accountability Act of 1996 ("HIPPA") , I have certain rights to privacy regarding my protected health information(PHI). I understand that this information can and will be used to:
I recieved, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosure of my PHI. I understand that this organizAtion has the right to changes its Notice of Privacy Practices from time to time and that I may contact this organisation at any time to obtain a current copy of the Notice of Privacy Practices.
Practice Use Only