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CONSENT TO RELEASE PERSONAL HEALTH INFORMATION (PHI)

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our notice before signing this consent and prior to any service being provided to you by the Practice. The Practice reserves the right to change the Notice of Privacy policies. If we change our notice, you may obtain a revised copy by sending a letter to the Practice’s HIPAA Officer or by asking the provider’s receptionist. You can also obtain a copy on the clinic’s website at www.ncdhp.com.

By signing this form, you acknowledge that you have been given an opportunity to read the clinic’s Notice of Privacy Practices prior to any service being provided to you by this Practice, and you consent to the use and disclosure of your medical information to other healthcare providers involved in your care and for treatment, payment and healthcare operations. You have the right to revoke this consent in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health (HITECH).

I authorize Physicians/staff of DIGESTIVE HEALTH PARTNERS to release information pertaining to my condition and/or care to those individuals listed below:

List

Name

Date of Birth

Relationship

Contact Phone Number

Digestive Health Partners physicians and staff may contact me in the manner: (Check all that apply)

Preferred Method of Contact (please check)(Required)

Home Telephone

Cell Number

Home Telephone

Cell Number

Work Telephone

Patient Portal Email(Required)

I hearby acknowledge that I can request a copy of this office's Notice of Privacy Practices.

Signature of Patient/Legal Representative(Required)

Date

If Legal Representative, relationship to patient

WE CANNOT SPEAK TO ANYONE YOU HAVE NOT LISTED ABOVE.
THIS FORM MUST BE COMPLETED AND SIGNED

Name of Patient

Date of Birth

Financial Policy

Payment at the Time of Service

As a courtesy, we will bill your insurance for all billable services; however, you will be expected to pay any portion of your cost not covered by your insurance due to deductible, co-insurance, or co-payments on the day of service.

Submission of Claims

Your health insurance plan is a contract between you and your insurer. It is the patient’s responsibility to understand their insurance policy limitations. In the event your health insurance determines that they will not cover a service that you have received, you will be responsible for payment. Our business office can provide additional information and support for disputes and appeals. Please note - patient diagnosis cannot be changed on, added to, or deleted from a claim in order to facilitate better insurance coverage.

Outstanding Balances

We urge you to keep your account current with our office. When an account balance becomes more than 90 days past due, it may be referred to an outside collection agency. At that time, any additional fees incurred will be the responsibility of the patient. If you need to make special payment arrangements, it is your responsibility to contact our business office before your account is sent to an agency. Minimum monthly payment arrangements may be made for no less than $50 per month, depending on the balance incurred.

Payment Plans

Only an approved, official, and signed payment plan document will stand as an acceptable payment agreement. Incremental payments made apart from an official payment plan will not be recognized as a payment arrangement between a patient and Asheville Gastroenterology Associates.

Overpayments

In the event of an overpayment, our office will work to refund any applicable credits, minus any balances, as quickly as possible.

Returned Checks, NSF, Closed Accounts

Payments made to Asheville Gastroenterology Associates that are not honored by the bank will incur a returned check fee of $35.00.

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