Welcome to Internal Medicine And Primary Care Of Sebastian LLC. Please take a moment to review and sign this Registration and Consent for Treatment.
Internal Medicine And Primary Care Of Sebastian LLC reserves the right to make changes to this form. If changes are made you will be presented with a new form for signature. Our clinic staff is available to answer any questions you may have.
1. Social Security Disclosure Statement
Disclosure of your Social Security Number (SSN) is requested from you in order for Internal Medicine And Primary Care Of Sebastian LLC to facilitate positive patient identification. No statute or other authority requires that you disclose your SSN for that purpose. Failure to provide your SSN, however, may result in a lack of positive patient identification. Further disclosures of your SSN are governed by the Public Information Act (Chapter 552 of the Texas Government Code) and other applicable laws.
2. Patient Rights and Responsibilities
Internal Medicine And Primary Care Of Sebastian LLC acknowledges that I have certain rights as a patient, and I acknowledge I have certain responsibilities as a patient. This information (including how to register complaints I may have) is posted throughout the clinic and a written copy was given to me at the time of my visit.
3. Consent For Treatment
I, voluntarily present to Internal Medicine And Primary Care Of Sebastian LLC for medical evaluation, diagnosis, and/or treatment. I consent and authorize my provider(s) or his or her designee(s) to provide diagnostic and therapeutic treatment, which may be necessary or advisable in their professional judgment. Internal Medicine And Primary Care Of Sebastian LLC welcomes medical residents; students, including nursing; and approved observers engaged in an educational purpose; all of whom are under the direct supervision of a privileged provider or staff member. By signing this consent form, I do not waive my right to refuse recommended tests or treatment(s). I authorize and consent to the use of recordings, films, or other images of me (i.e., any photographic, video, electronic or audio media) for purposes of identification, diagnosis, or treatment in connection with the care provided to me.
4. Agreements and Understandings:
a. I have the right to consent or refuse to consent, to any proposed procedures or therapeutic courses of treatment.
b. I understand that my physician may be an employee of UTSouthwestern
c. I understand that regardless of my assigned insurance benefits,
I AM RESPONSIBLE FOR AND DO HEREBY EXPRESSLY ASSUME FINANCIALLY RESPONSIBILITY FOR the total charges for a physician, medical, and other services rendered.
d. I understand that Internal Medicine And Primary Care Of Sebastian LLC has the right to pursue full collection efforts including asset credit checks and litigation.
5. Release of Information
a. I understand that as part of my health care, Internal Medicine And Primary Care Of Sebastian LLC personnel and my physician create and maintain a record of the care and services provided. I also understand that such information may be used and/or disclosed in the management and delivery of care and services provided by Internal Medicine And Primary Care Of Sebastian LLC to me, as described in the Notice of Privacy Practices.
b. I understand and acknowledge that Internal Medicine And Primary Care Of Sebastian LLC participates in an electronic medical record exchange program with other healthcare facilities and providers (“Exchange Participants”). I understand that when I seek treatment from Internal Medicine And Primary Care Of Sebastian LLC or Exchange Participants, my health information may be shared electronically between Internal Medicine And Primary Care Of Sebastian LLC, UT Southwestern, and Exchange Participants in order to provide care and services to me, and I do hereby authorize Internal Medicine And Primary Care Of Sebastian LLC to share my health information in this manner with Exchange Participants. I also understand that my health information may include certain “Sensitive Information” such as genetic information and diagnoses or treatments for substance abuse, mental illness (excluding psychotherapy notes), or communicable diseases(including HIV or AIDS) and that some Sensitive Information cannot be disclosed through the medical record exchange program without separate authorization by me.
c. I understand and acknowledge that as part of receiving my health care satellite Internal Medicine And Primary Care Of Sebastian LLC, my physician and other personnel engaged in my care may electronically request my prescription medication history from participating pharmacies, pharmacy benefit managers, or payers and that such prescription medication history may become part of my medical record.
6. Assignment of Benefits and Financial Agreements
a. I hereby assign to Internal Medicine And Primary Care Of Sebastian LLC, and any practitioner providing care and treatment to me, any and all benefits and all interest and rights for Services rendered under any insurance policies, including but not limited to Medicare, Medicaid, Tricare, or any reimbursement from a pre-paid health care plan. I certify that the information given by me in applying for payment under any medical insurance program, including Medicare and health care plan. I certify that the information given by me in applying for payment under any medical insurance program, including Medicare and Medicaid, is correct. This means that Internal Medicine And Primary Care Of Sebastian LLC will be entitled to directly receive all insurance payments on my behalf. If my treatment was caused by events that result in legal action, I assign to Internal Medicine And Primary Care Of Sebastian LLC any interest in any claims I may have to the extent necessary to fully reimburse Internal Medicine And Primary Care Of Sebastian LLC for the rendering of services to me.
b. understand that, regardless of my assigned insurance benefits, I am financially responsible for payment of services rendered to me. In addition, I will be financially responsible for my spouse and my child/children that is/are born or treated by Internal Medicine And Primary Care Of Sebastian LLC or its physicians. If the providers involved in my care accept third-party reimbursement for all or part of the services I receive, I hereby agree to assign such benefits to Internal Medicine And Primary Care Of Sebastian LLC and authorize my insurance company, governmental program, or other entity to make payment directly to Internal Medicine And Primary Care Of Sebastian LLC I understand that Internal Medicine And Primary Care Of Sebastian LLC may disclose a limited amount of health information to third parties to obtain payment for the healthcare services provided.
c. I agree to pay co-payments, co-insurance, deductibles, and outstanding balances. Internal Medicine And Primary Care Of Sebastian LLC will honor any arrangements and/or agreements entered into with my insurance company or third-party payers. I understand that I will not be billed for amounts that Internal Medicine And Primary Care Of Sebastian LLC is contractually or legally obligated to discount. If I am injured and receive treatment at Internal Medicine And Primary Care Of Sebastian LLC, I agree to assign to Internal Medicine And Primary Care Of Sebastian LLC my interest in any lawsuit or settlement to the extent necessary to fully pay Internal Medicine And Primary Care Of Sebastian LLC for the treatment. If my account becomes delinquent and is referred to an attorney or collection agency for collections, I agree to pay reasonable and necessary attorney's fees and collection expenses.
7. Valuables
I understand that Internal Medicine And Primary Care Of Sebastian LLC does not assume the responsibility for the safe keeping of any personal property.
8. Notice of Privacy Practices
I acknowledge that I received a Notice of Privacy Practices as part of this encounter. I understand that a copy of the Notice of Privacy Practice is available to me at any time upon my request. For more information visit
www.hhs.gov/ocr/privacy/hipaa/...
9. Recording Prohibited
I understand that Internal Medicine And Primary Care Of Sebastian LLC policy prohibits patients and visitors from using personal devices to take photographs, video, audio, or another recording of any procedure, service, treatment, or medical records. This prohibition includes recording and sharing of any kind, such as social media, live streaming, and real-time applications (e.g., Snapchat, FaceTime, Skype).
I have read the above document and understand its contents. I acknowledge that I am the patient or I am the patient's legally authorized representative, and/or guarantor and consent to the above items and make the acknowledgments hereby made.
