Privacy and Billing Procedures The Urgency Room

The Urgency Room’s Privacy and Billing Procedures Authorization and Acknowledgement

These authorizations/acknowledgements cover all services rendered to me, or the patient I am signing for, today and all future dates of service. I understand I may revoke this authorization by informing The Urgency Room in writing, but if I do revoke this authorization, it will not affect anything prior to the date the revocation is received by The Urgency Room.

 

Acknowledgement of Receipt of Notice of Privacy Practices Authorization to Release Information to Family/Friends or Others

I have received a copy of The Urgency Room’s Notice of Privacy Practices. I authorize The Urgency Room to release any information regarding my treatment; including lab results, x-rays, and medical records, to the following individuals/entities (The Urgency Room may not release information or records to the names individuals/entities unless you identify them here):

Name _______________________ Relationship to Patient ________________________

Name _______________________ Relationship to Patient ________________________

Name _______________________ Relationship to Patient ________________________

Name _______________________ Relationship to Patient ________________________

The Urgency Room will use my home phone number and primary address supplied during registration to contact me regarding my treatment; including lab results, x-rays, and medical records. I will ensure this information is up to date at every visit.

 

Authorization to Treat and Bill

I consent to be treated by The Urgency Room. If I am not the patient being treated, I am authorized to consent to treatment and billing for the patient identified below. I authorize The Urgency Room to bill my medical insurance for the care I receive and to release any information the insurance carrier requires to process this bill. I authorize payment of medical benefits to The Urgency Room, or to outside labs as described below, for all services performed and billed by The Urgency Room. I understand that I am responsible for all charges for the treatment I receive at The Urgency Room. I understand that The Urgency Room providers may utilize the Prescription Monitoring Program service at no additional charge to me.

 

As a courtesy, The Urgency Room will bill my medical insurance. If I do not provide complete and accurate insurance information to The Urgency Room, I understand The Urgency Room may not receive payment for my carrier and I will be entirely responsible for my bill. Even after my medical insurance company pays The Urgency Room’s bill, I may owe The Urgency Room payment for services not covered by my insurance and I agree to pay these promptly to The Urgency Room. I understand that The Urgency Room may send lab specimens to an outside laboratory. I authorize any lab performing services for me to bill my medical insurance for their services. I understand that my medical insurance may not pay for all services provided by the lab and I agree to pay any remaining balance promptly to any outside lab providing services to me. I understand that The Urgency Room is not responsible for payment to outside labs for tests provided to me.

 

To protect my privacy and prevent fraud, I understand that if I cannot provide acceptable photo identification at the time of service, The Urgency Room may choose not to bill insurance and may decline credit/debit cards and checks as a form of payment. I understand that if I fail to pay The Urgency Room for services provided to me, the balance owed may be sent to collection and I may incur collection fees of up to 25% in addition to the amount owed for services/treatment rendered. I understand that I may contact The Urgency Room to work out payment arrangements that may prevent this additional cost.

 

Signature ____________________________________________ Today’s Date _________________

Patient Name _________________________________________ Patient’s Date of Birth _____________

Name of Patient

Representative *_______________________________________ Relationship to Patient* ____________

*(Required if the patient is a minor or if the patient is unable to sign this form.)

Version 10.05.15