Office Policies: Authorization to Release Health Information & Assign Benefits
Release of Information
I authorize Parkhurst NuVision to disclose all or any part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corporation (1) which is or may be liable or under contract to Parkhurst NuVision for reimbursement for services rendered, and (2) any health care provider for continued patient care. Parkhurst NuVision may also record and disclose on an anonymous basis any information concerning my case, which is necessary or appropriate for quality and training purposes, the advancement of medical science, medical education, medication research, for the collection of statistical data or pursuant to State or Federal law, statute or regulation. A copy of this authorization may be used in place of the original.
Privacy Practices
The law requires that Parkhurst NuVision make every effort to inform you of your rights related to your personal health information. By signing below, I acknowledge that I may follow this link to read or have access to Parkhurst NuVision’s Notice of Privacy Practices, or that I may request a copy of this notice upon arrival at the office, and agree to continue my care with Parkhurst NuVision under said terms.
Medicare (if applicable)
I request that payment of authorized Medicare benefits be made on my behalf to Parkhurst NuVision, for services provided to me by Parkhurst NuVision. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the CMS-1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. Parkhurst NuVision accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance, and noncovered services. Coinsurance and deductible are based upon the charge determination of Medicare Carrier.
Commercial Insurance (if applicable)
I understand that Parkhurst NuVision maintains a list of health care service plans with which it contracts. A list of such plans is available from the business office. Parkhurst NuVision has no contract, expressed or implied, with any plan that does not appear on the list. The undersigned agrees that I am individually obligated to pay the full charges of all services rendered to me by Parkhurst NuVision if I belong to a plan that does not appear on the above-mentioned list.
Non-Covered Services (if applicable)
I understand that Parkhurst NuVision’s contracts with health care service plans relate only to items and services which are covered by the health care service plans. Accordingly, the undersigned accepts full financial responsibility for all items or services, which are determined by the health care service plans not to be covered.
Financial Agreement
I agree that in return for the services provided to the patient by Parkhurst NuVision, I will pay my account prior to the time service is rendered. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the patient, is hereby assigned to Parkhurst NuVision. If copayments and/or deductibles are designated by my insurance company or health plan, I agree to pay them to Parkhurst NuVision. All charges are my responsibility, whether or not my insurance company pays. Not all services are covered in all contracts. Some insurance companies arbitrarily select certain services they will not cover. Parkhurst NuVision cannot become involved in disputes between me and my insurer regarding covered charges, deductibles, or copays. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate.
