CENTRAL TEXAS MEDICAL ASSOCIATES - Live Oak Health …



LIVE OAK HEALTH PARTNERS

Patient Information Form

|Social Security# Name: Last First MI |

|Address City State Zip |

|Home Phone Cell Phone Primary Care Physician |

|Date of Birth Sex: M F Marital Status |

|Race Ethnicity Preferred Language |

|Emergency Contact Phone Number |

|Name of Responsible Party: Last First MI |

|Social Security# Relationship to Patient Sex: M F |

|Address City State Zip |

|Home Phone Work Phone Birth Date |

|Insurance Company/Carrier Phone Number |

|Address City State Zip |

|Name Policy Holder Social Security# |

|Member# Group# Policy Holder Date of Birth |

|Employer Insurance Plan Yes No Employer |

| |

|Secondary Insurance Company/Carrier Phone Number |

|Address City State Zip |

|Name Policy Holder Social Security# |

|Member # Group# Policy Holder Date of Birth |

|Employer Insurance Plan Yes No Employer |

|RELEASE OF MEDICAL INFORMATION: I hereby consent and authorize Live Oak Health Partners to release any medical information in connection with the services rendered |

|for determination of benefits or collection of said benefits from my health insurance carrier. |

| |

|__________________________________________ _______________________ |

|Signature Date |

CONSENT TO TREAT- ASSIGNMENT OF BENEFITS- FINANCIAL AGREEMENT-HIPPA

While I am here, I permit the employees, the doctor and all other persons caring for me to treat me in ways they judge are beneficial to me. I understand the medical provider will explain to me the nature of my condition and his/her recommended treatment and any associate risk involved. I also understand that he/she will explain to me other ways this condition could be treated. I further understand that this care may include tests, examinations, medical and/or surgical treatment. No guarantees have been made to me about the outcome of this care.

I hereby authorize Live Oak Health Partners to release to release all information necessary to secure payment. I assign all benefits for unpaid services to with I am entitled to Live Oak Health Partners . This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.

I request that payment of authorized Medicare and Medigap benefits be made on my behalf to Live Oak Health Partners . I authorize any holder of medical information about me to release to Medicare (HCFA) and its agents and/or Medigap any information need to determine these benefits or the benefits payable for related services.

I have received and read the Financial Policy, and understand I am financially responsible for all charges whether or not they are covered by insurance . In the event of default, I agree to pay all costs of collection and reasonable attorney’s fees.

By signing below, I acknowledge receipt of Live Oak Health Partners Notice of Patient Privacy Practices “Acknowledgement”.

Signature:_______________________________________________ Date:_____________________________

Live Oak Health Partners, a Member of Adventist Health System

Consent to Release of Health Care Information

(Texas)

General Release of Information

I acknowledge that I have received a copy of the Physician Office’s Notice of Patient Privacy Practices, which describes the permitted uses and disclosures of my health care information related to my care by the Physician Office, and payment of my charges for the services received at the Physician Office. I specifically authorize the uses and disclosures of my health care information described in the Physician Office’s Notice of Patient Privacy Practices.

I CONSENT to release of my health care information, including but not limited to medical, psychiatric, substance abuse or HIV information, for medical purposes and for payment purposes to third parties including but not limited to federal or state health plans, insurance companies, collection agencies, employers or other organizations responsible for payment of my charges for the services received at the Physician Office,

_____ Except for the following. (you can use one of the categories listed above, but you must specify) _______

___________________________________________________________________________________

____________________________________________________________________________________

_____ No Exceptions (please initial _________)

I consent to release of the following health care information to the Physician Office’s institutionally related foundation for fundraising purposes: name, address and other contact information, age, gender, dates of services, and insurance status.

Affiliated Entities of Adventist Health System

I consent to the use and release of all my health care information, including but not limited to mental health, HIV/AIDS, genetic testing, venereal disease, and rape/sexual assault information, for treatment, payment and health care operations, among the affiliated entities of Adventist Health System listed in the Physician Office’s Notice of Patient Privacy Practices, as amended from time to time.

Health Information Exchange

Health information exchange allows health care providers to share health care information about patients electronically for several purposes, such as treatment, quality assurance and state law reporting requirements. I understand that if I go to the Physician Office for treatment, the Physicians and/or their staff may get a copy of my health care information electronically through various health information exchange connections with other health care providers.

I understand I may request that my health care information not be shared through electronic health information exchange by following the directions in the Hospital’s Notice of Patient Privacy Practices.

Substance Abuse

I authorize the Physician Office and Adventist Health System to release all of my substance abuse health care information (which includes drug and alcohol abuse information) to the hospitals, physicians and care providers who are treating me and are affiliated with (owned or operated by) Adventist Health System for my treatment, payment of the health care services I receive and health care operations activities, like quality assurance and peer review. The list of Adventist Health System affiliated entities is available in hard copy form at the front desk of any site of service or on the websites of Adventist Health System.

I understand that this authorization for release of substance abuse health care information may be terminated at any time, unless Adventist Health System and its affiliated hospitals, physicians and care providers have already acted in reliance on it. If not previously revoked, I understand that this authorization is effective until I die. I further understand that I may decline to sign this authorization today by checking the box below.

_______ I DECLINE

THE UNDERSIGNED MAY RECEIVE A COPY of this agreement UPON REQUEST, and CERTIFIEs THAT HE OR SHE HAS READ THIS RELEASE and has been able to ask questions.

______________________________________________________

Printed Name of Patient Printed Name of Witness

______________________________________________________

Patient’s Signature & Date Witness’ Signature & Date

_________________________________________________________ ______________________________________________________

Printed Name of Legal Representative/Principal Obligor Legal Representative/Principal Obligor’s Signature & Date

_________________________________________________________ ______________________________________________________

Relationship to Patient (Self, Legal Representative, Printed Name of Interpreter [if applicable]

Principal Obligator, General Agent)

IF THE PATIENT, PRINCIPAL OBLIGOR, LEGAL REPRESENTATIVE, OR GENERAL AGENT IS ONLY ABLE TO GIVE VERBAL CONSENT, AS AN EMPLOYEE OF THE PHYSICIAN OFFICE I HAVE SIGNED THIS FORM ON BEHALF OF THE PATIENT TO ACKNOWLEDGE THE VERBAL CONSENT BY THE PATIENT OR THE PATIENT’S PRINCIPAL OBLIGOR, LEGAL REPRESENTATIVE, OR GENERAL AGENT, TO THE PROVISION OF TREATMENT BY THE PHYSICIAN OFFICE.

______________________________________________________

Printed Name of Patient Reason Verbal Consent Obtained

______________________________________________________

Printed Name of Individual Providing Verbal Consent Relationship to Patient (Self, Principal Obligor, Legal Representative or General Agent)

______________________________________________________

Printed Name of Hospital Employee Printed Name of Witness

______________________________________________________

Physician Office Employee’s Signature & Date Witness’ Signature & Date

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RESPONSIBLE PARTY INFORMATION (person responsible for payments not covered by insurance)

INSURANCE INFORMATION

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