Liberty Orthopedic Associates, Pc s1

LIBERTY ORTHOPEDIC ASSOCIATES, P.C.

CO-PAYS ARE DUE AT THE TIME OF YOUR VISIT.

CONCERNING INSURANCE

Patients who carry health care insurance should remember that professional services are rendered and charged to the patient and not to the insurance company. We will file your original claims. This office cannot accept responsibility for collecting your insurance claim or for negotiating a settlement on a disputed claim. You are ultimately responsible for payment of your bill, after insurance has responded, for the medical services rendered by Liberty Orthopedic Assoc.P.C.. Some insurance companies, including Medicare and Blue Cross and Blue Shield, will send the check directly to you. If your insurance company pays us after you have already paid us, a refund check will be sent to you.

If you are covered under worker’s compensation, please make sure we have all the necessary information for filing your claim for services.

I hereby authorize Liberty Orthopedic Associates to release information to insurance companies and referred physicians concerning my medical treatments. I further authorize payments of benefits directly to Liberty Orthopedic Associates, P.C... I understand I am financially responsible for all charges.

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Signature of patient or parent if minor Date

Notice of Privacy Practice’s Acknowledgement

I acknowledge, by my signature below, that I was offered a copy of the Facility’s Notice of Privacy Practices.

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Patient or Representative and Relationship to Patient Date

AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I,________________________________ , date of birth____________, consent to and authorize Liberty Orthopedic Associates, P.C. to release my medical information to include as follows:

HIPPA laws require that if you have been treated for these special categories, mark either YES, NO. If they do not apply then mark NA.

□ Yes □ No □ NA 1) Alcohol and drug abuse treatment □ Yes □ No □ NA 3) HIV status or AIDS

□ Yes □ No □ NA 2) Mental health □ Yes □ No □ NA 4) Genetic Information

The following are the individuals whom I will allow to receive information regarding myself. This could include examples such as requesting copies of medical records, making appointments, picking up prescriptions, requesting copies of x-rays, picking up medical leave forms.

________________________________________________________Relationship_________________

I understand this authorization may be revoked in writing at any time except to the extent already acted upon. To revoke this authorization I must send a request in writing to: Liberty Orthopedic Associates, P .C... This authorization expires one (1) year from the date signed. I understand that treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization

I understand that my information used or disclosed by this authorization may be redisclosed by the recipient and may no longer be protected by the Privacy Regulations. A photostatic copy of this authorization shall be considered as effective and valid as the original.

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Signature of Patient or Personal Representative and Relationship Date