Pain and Wellness Solutions of the Carolinas Treatment Consent Form
and Financial Policies
I. AUTHORIZATION TO REQUEST MEDICAL RECORDS
This consent allows Pain and Wellness Solutions of the Carolinas (PWSC), PC to request your medical records from other physicians. By allowing these requests, we can improve the efficiency of your care. You also agree to pay any records fees that are charged by the practice providing the records.
I hereby authorize Pain and Wellness of the Carolinas, PC to request my medical records and protected health information as it deems fit for my treatment.
II. PATIENT PAYMENT AND BILLING POLICY (FINANCIAL POLICY)
At Pain and Wellness Solutions of the Carolinas, we take great care to provide quality, cost-effective, medical care. In order to do so, we rely on accurate and up to date insurance information.
The information you have provided will be used for billing purposes including obtaining payment for service(s) and treatment provided. This information is necessary for Pain and Wellness of the Carolinas (PWSC), PC, to process your claim(s) with your health insurance company and to expedite your claim(s) without delays.
I hereby authorize my insurance company to send all payments for medical services rendered to me (or my dependents) directly to Pain and Wellness Solutions of the Carolinas. I understand that this assignment of benefits is irrevocable and any reproductions shall be considered legal and binding as the original.
With my signature below, I confirm the demographic and insurance information is true and correct, and for any future services this authorization applies to. If the information is found to be inaccurate, I agree to be personally responsible for payment in full for services provided. Missing or incomplete information will be subject to non-payment or denial and any unpaid balance will revert to the patient's responsibility.
I further authorize the release of any information (including medical information) to my insurance company, primary care provider, and referring or consulting physicians, if needed and as necessary, to process insurance claims, insurance applications and prescriptions as well as coordinating care.
I also acknowledge that all charges for professional service(s) rendered are due at the time of service(s) unless insurance is applicable. As a courtesy to you (unless mandated by the health plan in which this practice participates), PWSC will file your claim with your insurance; however, all co-pays, co-insurance, and deductibles are due at the time of service. Credit card, cash or checks accepted. There will be an associated fee for insufficient funds for checks.
I understand I am financially responsible for all services not covered by my health plan. Also, balances allowed by your health insurance company after insurance payment will be the responsibility of the patient (you) or guardian. A payment plan can be arranged if you are experiencing difficulty with making the payment in full.
Should my insurance plan not forward notice of payment and/or a benefits statement within 60 days from the date of service, I will be responsible for payment in full.
I also understand that should I be covered by a health plan Pain and Wellness Solutions of the Carolinas is participating with at the time services are provided, I shall only be responsible for those services authorized and approved by my plan.
A COPY OF THIS AUTHORIZATION MAY BE CONSIDERED AS AN ORIGINAL FOR INSURANCE PURPOSES.
I also agree that it is my responsibility to notify our office of any changes to personal or insurance information. Failure to provide prompt notification may result in termination of services.
III. ADDITIONAL INSURANCE INFORMATION
We accept assignments from Medicare and other major health insurance; however, we do require the 20% co-pay from Medicare members or the co-payment for any HMO insurance. We cannot bill your insurance unless you bring all your insurance information and an original claim form. Your insurance policy is a contract between you and your insurance company, and we are not part of the contract. In the event we do accept assignment of benefits, we require that you be pre-approved for our Extended Payment Plan with the authorization to bill that account for the balance. If your Insurance has not paid your account in full within 45 days, the balance of your account will be automatically billed to you. Please be aware some and perhaps all of the services provided may be “non-covered” services and not considered reasonable and necessary under the Medicare Program and/or other medical insurance. Our practice is committed to providing the best treatment possible for our patients, and we charge what is usual and customary for our area.
IV. MISSED APPOINTMENTS POLICY
Unless canceled at least 48 hours in advance, our policy is to charge for missed appointments at the rate of $30.00 for a clinic visit. For a procedure visit, the missed appointment rate is $50.00.
Please help us serve you better by keeping your scheduled appointments.
V. ARRIVAL POLICY and LATE POLICY
Please arrive for all appointments at least 15 minutes ahead of time to fill out computer work/paperwork and administrative check-in. We may not be able to see patients who are 15 minutes or more later.
VI. GENERAL CONSENT FOR CARE AND TREATMENT
TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been
recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at any of our practice locations. The consent will remain fully effective until it is revoked in writing. You have the right to discontinue services at any time.
You have the right to discuss the treatment plan with your physician about the purpose, potential risks, and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your physician, we encourage you to ask questions.
I voluntarily request a physician or his designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).
By signing below, I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
VII. PATIENT PORTAL COMMUNICATION
At Pain and Wellness Solutions of the Carolinas we have implemented a patient portal, which allows for secure electronic communication regarding your medical care. This will be able to use to request appointments, prescription refill requests, labs results and other functionality.
I understand giving my email address to Pain and Wellness Solutions of the Carolinas will be interpreted as my consent to receive secure electronic communication via the patient portal regarding my medical care. I understand that electronic communication occurs only through the patient portal. At no time will you ever receive a direct email regarding your medical care. In your email box you will receive a message that a secure message is waiting on your patient portal account in which you will login in order to receive the message (this is similar to the way financial institutions securely communicate). I understand the terms and I consent to the use of the patient portal in addition to the other methods of communication with Pain and Wellness Solutions of the Carolinas. ` I understand that message via the patient portal or any form of electronic communication is never appropriate for urgent or emergency situations.
VIII. RELEASE OF INFORMATION
PWSC will not discuss your medical conditions with any member of your family unless you specifically designate an individual and sign our separate release policy.
IX. HIPAA PRIVACY PRACTICES NOTICE
I hereby affirm that I have received or been offered a copy of the Notice of Privacy Practices from Pain and Wellness Solutions of the Carolinas. Under federal law 104-191, also known as HIPAA, I am entitled to receive a copy of this Notice from my healthcare provider.
I understand that my signature on this Acknowledgement below only signifies that I have received or been offered a copy of the Notice, and does not legally bind or obligate me in any way.
I understand that I am entitled to receive a copy of the Notice of Privacy Practices from my healthcare provider, whether I sign this Acknowledgement or not.
BY SIGNING THIS FORM, YOU ACKNOWLEDGE THAT YOU:
agree to allow PWSC to request your medical records and protected health information as it deems fit for your treatment.
agree to abide by the PWSC Financial Policy
have read about PWSC Additional Insurance Information
understand the PWSC Missed Appointment Policy
understand the PWSC Arrival Policty and Late Policy
agree to the PWSC General Consent for Consent and Treatment
agree to the PWSC Patient Portal Communication policy
PWSC policy on Release of Information
have been provided with a copy of the HIPAA Privacy Practices Notice by PWSC