CONSENT FOR TREATMENT AND RELEASE OF INFORMATION
I consent to all health care services performed by First Choice Community Healthcare (FCCH), its employees, agents and affiliates, to include evaluation, diagnostic procedures, behavioral health, medical and dental treatment, as deemed necessary and appropriate by FCCH. I am aware of, and shall comply with, applicable FCCH policies as they relate to me as a patient of FCCH. I have been informed regarding FCCH Patient’s Bill of Rights and Responsibilities. Except as required by law or as otherwise described in this document and FCCH Notice of Privacy Practices, FCCH will not release my health information without my or my representative's valid written authorization. FCCH may share such information to carry out treatment, payment, or health care operations as described in the Notice of Privacy Practices.
I agree to advise my provider of any medications I am taking, of other providers I may be seeing, and of any sensitivities or allergies I may have to any medications. I agree to provide my health information to my provider and to FCCH staff recording that information in my patient record. Continued treatment will include updating my health information at least once a year. I understand it may be necessary to release my health information to other providers for my treatment and care.
I authorize FCCH to release my medical, behavioral, dental and/or billing records to individuals and entities as specified in the Notice of Privacy Practices and/or by federal and state law including health information which may be released to other health care providers who may be involved in my care. I understand that this authorization will remain in effect unless I revoke it in writing. Any revocation will affect disclosures necessary for payment for care provided to me by FCCH. This consent is separate from my written consent to release electronic health records which may be maintained by FCCH.
I will pay for all charges for services I or my dependent(s) receive and which are not paid for through a third -party payer including deductibles, co-insurance, co-payment or non-covered charges. Co-payments and past due balances are due at the time of appointment check-in, unless previous arrangements have been made. Payment must be in the form of cash, check or credit/debit card. Returned checks are subject to standard bank fees, payable by cash or money order only, in addition to the amount of the returned check.
Payment for Services: if you would like to apply for our sliding fee discount to help cover some of your out-of-pocket costs, we will need you to provide us certain financial information. The nominal fee for uninsured patients who qualify may vary by service type, and the percentage of total charges for a visit that are the patient’s responsibility to pay depends on family size and income. Your final bill for your visit may vary, according to the services you receive.
I authorize FCCH to release any part of my/my dependent's health records to any third-party payer, their agent or legal representative, as required for payment of my/my dependent's medical bills. I have the right to refuse this release if I assume full financial responsibility for any services provided. I appoint FCCH as my attorney-in-fact to collect any insurance benefits to which I/my dependent(s) may be entitled from any third-party payer, up to the amount of the charges for the services rendered.
I certify that the information I have given in applying for payment under Title XVII of the Social Security Act (Medicare) is correct. I consent to the release of my health information to the Social Security Administration and the Centers for Medicare and Medicaid Services, its intermediaries or carriers. I authorize that payment be made on my or my dependent's behalf to FCCH.
I consent to receive notifications from FCCH for my protected healthcare and other services at the phone number provided, including my wireless number provided. I understand I may be charged for such calls by my wireless carrier and that such calls may be generated by an automated dialing system.