Martinsville Physician Practices, LLC

Martinsville Physician Practices, LLC

CONSENT

CONSENT FOR EVALUATION

I hereby authorize Martinsville Physician Practices, LLC to perform evaluation and treatment relative to my injury/illness or physical examination as deemed necessary by the attending physician. I give permission for the attending physician to release physical examination and testing results to my employer and to release medical information only in accordance with applicable laws and regulations.

AUTHORIZATION TO RELEASE INFORMATION AND

ASSIGNMENT OF INSURANCE BENEFITS

I consent to the release from my medical records any information, including information related to psychiatric care, drug and alcohol abuse and HIV/AIDS, that may be required by my insurance carrier, employer, or government agency for the processing of my claims for medical benefits. I authorized the mentioned insurance companies to remit directly to Martinsville Physician Practices, LLC any medical benefits, otherwise payable to me.

STATEMENT OF FINANCIAL RESPONSIBILITY

If my outstanding balance is given to a collection agency or attorney for collection, I agree to pay reasonable collection cost which could include late charges, interest, court cost and/or attorney fees.

NOTICE OF DEEMED CONSENT TO BLOOD TESTING

A law was enacted in Virginia in 1993 which authorizes health care providers to test their patients/client’s when the health care provider is exposed to the body fluids of a patient in a manner which may transmit human immunodeficiency virus (HIV) and Hepatitis. Pursuant to this law, in the event of such exposure, you will be deemed to have consented to such testing, and to have consented to the release of the test results to the health care provider who may have been exposed. However, you would be informed before any of your blood would be tested (except in an emergency situation) for HIV, Hepatitis B, and Hepatitis C pursuant to this provision, the testing would be explained and you would be given the opportunity to ask any questions you might have. I have read and understand the above “Notice of Deemed Consent to Blood Testing.”

DURATION OF CONSENT

I hereby understand that, my signature gives consent for all sections mentioned above for a period of one year from the date signed.

Witness______Date______Signature______