Mid-South Financial Responsibility

MID-SOUTH FINANCIAL RESPONSIBILITY

SURGEONS, PLLC MEDICAL CONSENT FORM

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Patient Name: ______DOB: ______

CONSENT TO TREAT

I authorize MID-SOUTH SURGEONS, PLLC to provide the medical and surgical services, tests, procedures, drugs, supplies, and other care that my doctor decides are needed for my health and well-being. My authorization includes MID- SOUTH SURGEONS, PLLC and its clinical employees. My authorization includes my doctor and the other physicians or allied health care professionals of this practice who might be involved in my care. I understand that these services may include, for example, special tests or procedures, ordered by my doctor. I acknowledge that the practice of medicine is not an exact science. No one has guaranteed, nor can anyone guarantee, the results of the care provided at MID-SOUTH SURGEONS, PLLC.

ASSIGNMENT OF BENEFITS

I assign to MID-SOUTH SURGEONS, PLLC my right to receive payment from third-party payers. Third-party payers include payers (such as insurance carriers) who provide coverage to me, for care provided by MID- SOUTH SURGEONS, PLLC. Third-party payers also include others from whom benefits are, or may become, payable to me including but not limited to, legal settlements.

Medicare/TennCare/Champus Patients- If I am a Medicare or TennCare patient, I certify that the information I provided when applying for payment under the Social Security Act is correct.

RESPONSIBILITY FOR PAYMENT

·  I will pay for all my care provided by MID-SOUTH SURGEONS, PLLC and not paid for by my insurance or third-party payers. I will pay for my care even if a third-party payer determines the care was medically unnecessary or not covered, or if a third-party payer denies authorization, either before or after care was provided.

·  I agree that the fees for my care will be set by the billing department and office manager of Mid-South Surgeons, PLLC.

·  I understand fees paid up front for services are ESTIMATES and that I may be billed charges for additional services

·  I agree to pay collection fees of 22% should my account need to be turned over to a collection agency, as well as any attorney fees should one be required to collect my account.

I HAVE READ, OR HAD READ TO ME, THE INFORMATION ON THIS FORM. I HAVE HAD THE OPPORTUNITY TO ASK ANY QUESTIONS AND HAVE THEM ADDRESSED. BY VOLUNTARILY SIGNING MY NAME BELOW, I INDICATED THAT I UNDERSTAND AND ACCEPT THESE PROVISIONS.

Signature of Patient: ___ Date: _____

Name of Personal Representative (if applicable): ______

Signature of Personal Representative: DOB: _____

Relationship to Patient: ______