Acknowledgement of Receipt of Privacy Practices



Last Name:First Name:Middle Initial:Address:City:State:Zip:Home Phone:( ) -Cell Phone:( ) -Email:Gender:MFAge:S.S.# - -Birth Date: / /Marital Status:MSDWSpouse’s name if married:Person to contact in case of an emergency:Phone:( ) -Responsible Party Information (if applicable):Last Name:First Name:Middle Initial:Address:City:State:Zip:S.S.# - -Employer:City:Phone:( ) -Insurance Information:Primary Insurance Company:Subscriber Name:Date of Birth: / /S.S.# - -Relationship to patient:Secondary Insurance Company:Subscriber Name:Date of Birth: / /S.S.# - -Relationship to patient:It is MY responsibility to obtain a referral from my primary care physician prior to treatment, if one is required by my insurance company. Failure to do so will result in the entire cost being billed to ME. I will not be able to be seen by the doctor if a referral is not present at the time of my appointment. I authorize the release of any medical information necessary to process my claims and request payment of benefits to the doctor who accepts assignment. I understand the provider’s charge may exceed the insurance payment, and if greater than such payment, I will be responsible for that amount. I also agree that any cosmetic procedures are not a covered benefit on my insurance plan and I will not request that they be billed to my insurance carrier. I understand that these charges are MY responsibility and are to be paid at the time of the visit. I authorize Michigan Specialty Clinic Pllc and his staff to conduct any test or procedure that they deem necessary to aid in diagnosis and/or treatment and I understand that these items will have a separate charge from the visit.Signature: Date: / /Patient or responsible personThank you for your confidence in choosing us to care for you and your family.Patient Authorization FormInsurance AuthorizationPatient Name: ____________________________I understand that if I have insurance, I authorize benefits to be made to Michigan Specialty Clinic for any services furnished to me by the physician. I authorize any holder of medical information about medical release to the health care financing administration and its agents. I understand my signature requests that payment be made and authorized release of medical information necessary to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere for other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. Insurance assigned cases, the physician or supplier agrees to accept the charge determination of the insurance carrier as the full charge, and the patient is fully responsible only for the deductible, coinsurance, and non-covered services.Signature: ___________________________________ Date:_________________Payment Authorization and Release of Information:As a patient of Michigan Specialty Clinic, I authorize the physician to exam, diagnose, and render all treatment as deemed necessary. If care is needed for any minor/disabled child or relative custodial to me, I authorize the same treatment for them also. I authorize Michigan Specialty Clinic to perform any procedure during my visit he deems necessary for my treatment. I also authorize Michigan Specialty Clinic to allow sharing of my photographs for the purpose of training, teaching, and medical illustration.I have requested that Michigan Specialty Clinic bill my insurance company for covered services provided by the facility here on my behalf. I authorize payment directly to the claim. I understand that it is still my responsibility to make sure that the bill is paid in a reasonable time. If, for any reason, any portion of my bill is not paid by my insurance, I further agree to make arrangements for prompt payment of the bill.I understand that I am financially responsible for all charges not covered by this assignment.I further understand that it is my responsibility to obtain referrals from my PCP if I have an HMO plan prior to my visits and agree to pay in full for the office visit and In order to process a claim for benefits, I authorize the physician and his representatives to release to my insurance company any information regarding my medical history, treatment, symptoms, examination results, or diagnosis necessary for payment of the claim. If this is a workers compensation claim, I authorize release of information to this carrier also, whether written or oral, for payment of this claim. If I am not insured, I assume full responsibility for all charges for services rendered and agree to pay in full at the time of the visit. Payment is due in full when services are rendered.Signature: _________________________________ Date: ______________________As a patient of Michigan Specialty Clinic, I agree to resolve all future claims, legal or equitable arising out of the treatment and medical services provided, through binding arbitration conducted in accordance with the arbitration rules of the American Arbitration Association as they relate to medical treatment. I understand that Michigan Specialty Clinic does not provide an insurance policy to cover these services. Any award shall be proved by sufficient evidence and the arbitration shall be binding and enforceable according to the laws of the State of Michigan. IT IS FURTHER AGREED:In the event that I breach this agreement, damages including reasonable costs and attorney’s fees shall be paid to Michigan Specialty Clinic.In the event my claim is deemed frivolous, damages including reasonable costs and attorney’s fees shall be paid to Michigan Specialty Clinic. This agreement shall be binding on heirs, executors, administrators, successors, assigns, agents & attorneys.IN WITNESS, the parties have signed this agreement.__________________________________________________________SIGNATURE OF PATIENT DATE__________________________________________________________ SIGNATURE OF WITNESS DATE Acknowledgement of Receipt of Privacy PracticesI, ___________________________, have received a copy of this office’s Notice of Privacy Practices. _______________________________________________________________________ Print Name _______________________________________________________________________ Signature Date* You may refuse to sign this acknowledgement.For Office Use OnlyWe attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:Individual Refused To SignCommunications barriers prohibited obtaining the acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther (Please Specify) ................
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