DISCLOSURE TO FAMILES AND LOVED ONES (EMERGENCY CONTACTS)

I authorize Primary Care House Calls, to disclose my health care information and to discuss my health care needs to those that I designate. I further authorize the release of my billing information and give these individuals the ability to pick up prescriptions and /or medications on my behalf. A photo ID is required for prescription pickup. These individuals will be considered my emergency contacts. Without authorization, no information may be shared. I authorize Primary Care House Calls to disclose my personal health information to the following people.

CONSENT TO TREATMENT FOR ALL PATIENTS

I hereby grant authorization and consent for medical treatment and/or procedures for myself or the patient for whom I am the legally authorized representative for whom I am signing and understand that no guarantee or assurance has been made as to the results for which may be obtained.

PHOTO DOCUMENTATION

I hereby grant authorization for Primary Care House Calls, Medical House Calls to make a copy of my photo identification to be included in my confidential record as well as to take a digital picture for additional protection against the theft of my medical identity. I further grant authorization for the clinical staff to take photo documentation of any injury or procedure that they feel is medically necessary to include in my confidential medical record.

NOTICE OF PRIVACY PRACTICES

I received a copy of the Primary Care House Calls, Privacy Practices and agree with these policies.

INSURANCE ASSIGNEMENT AND FINANCIAL RESPONSIBILITY

I hereby authorize the offices of Primary Care House Calls, to release any medical information required during examination and treatment to my insurance, and I permit payment to Primary Care House Calls, from my insurance company for any benefits due for their services rendered. I recognize and accept responsibility for services rendered regardless of insurance coverage. This includes but is not limited to coinsurance, copayment, deductible, and noncovered services.
I understand that I am responsible for all charges incurred regardless of the insurance status. I agree to pay for services incurred after the patient has been charged for the office visit, such a labs, radiology, medical supplies, etc. I agree to pay my bill in full for services rendered by Primary Care House Calls providers.