ELMCITY CENTER
CONSUMER AGREEMENTS AND AUTHORIZATIONS
CONSENT
FOR TREATMENT. I hereby
consent to the treatment provided by Elm City Center
and its employees or
designees. I authorize the mental and physical health care services deemed
necessary or advisable by my caregivers to address my needs.
AUTHORIZATION FOR RELEASE OF
PERSONAL HEALTH INFORMATION.
I authorize use and disclosure of
my personal health information for the purposes of diagnosing or providing
treatment to me, obtaining payment for my care, or for the purposes of
conducing the healthcare operations of Elm City Center. I authorize Elm City
Center to release any information required in the process of applications
for financial coverage for the services rendered. This authorization
provides that Elm City Center may release objective clinical information
related to my diagnoses and treatment, which may be requested by my
insurance company or its designated agent.
ASSIGNMENT OF INSURANCE
BENEFITS/ PAYMENT GUARANTEE/ COLLECTION FEE.
I authorize payment to be made
directly to Elm City Center for insurance benefits payable to me. I
understand that I am financially responsible to Elm City Center for any
covered or non-covered services, as defined by my insurer. I understand that
if my account balance becomes overdue and the overdue account is referred to
a collection agency, I will be responsible for the costs of collection
including reasonable attorneys fees.
PRIVACY POLICY.
I acknowledge having received
Elm City Center’s, “Notice of Privacy Practices”. My rights including the
right to see and copy my record, to limit disclosure of my health
information, and to request an amendment to my record, is explained in the
Policy. I understand that I may revoke in writing my consent for release of
my health care information, except to the extent the Practice has already
made disclosures with my prior consent.
__________________________
____________________
___________
Consumer or Authorized Person
Signature Relationship
Date
__________________________
____________________
Witness
Signature Date
Consumer unable to sign. Verbal
consent given. Reason_____________________________
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Illinois
