1) CONSENT FOR MEDICAL TREATMENT
I hereby consent to any and all (including emergency) treatment and services, diagnostic procedures, tests, and medical
treatment required for the diagnosis of any illness or treatments by the physicians or his designee, medical staff and other agents, and/or employees of Shane Retina Additionally, I consent to the use of my non-identifiable medical data and non-identifiable photographs for educational purposes. I acknowledge that no guarantees have been made to me as to the results of test, examination, treatments, procedures or any other services rendered.
Additional Provision for Minors/Incapacitated Patient: I, the undersigned, acknowledge and verify that I am the legal guardian or custodian of the minor/incapacitated patient or otherwise have authority to act on their behalf for health care decisions.
2) RELEASE OF MEDICAL INFORMATION (Third-Party Payers, Guarantors, Physicians)
By signing this form, I hereby authorize Shane Retina to use and release information and/or copies of my medical records as necessary for my treatment, for payment for that treatment and for the health care operations of the provider treating me; including to a hospital, physician or other provider, guarantor of my accounts, or third-party payers for which I have assigned benefits for my treatment and care, and if requested, to my referring physician, or any other healthcare provider responsible for my care, and as otherwise provided in the Shane Retina Notice of Privacy Practices. This includes information pertaining to psychiatric and/or psychological care, alcohol and/or substance abuse, AIDS, ARC, or HIV diagnosis, testing and/or treatment for this period of illness. It also includes other admissions if related to the accident or illness giving rise to this visit, medical, and other information as necessary for the operations of Shane Retina, or as required to secure payment for charges incurred by me or on my behalf, including a diagnosis of my medical condition. Healthcare information may also be released to my employer’s designee when the services delivered are related to a claim under worker’s compensation. If I am covered by Medicare and/or Medicaid, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carries for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. I further authorize the Department of Health and Human Services and/or Social Security Administration to release any confidential case information related to my application for government assistance requested by Shane Retina
3) RELEASE OF LIABILITY FOR LOSS OF PERSONAL PROPERTY
I have been advised that it is in my best interest to keep my valuables at home. Accordingly, I hereby release Shane Retina and the facilities in which services are rendered, from liability resulting from the loss by theft or
negligence of any employee of the practice or of any third party. I agree that I am responsible for any item(s) I keep with me in my possession including, but not limited to, money, clothing, eyeglasses, jewelry, dentures, or any other personal items.
4) ASSIGNMENT OF BENEFITS
In executing the assignments of benefits, I am directing the health insurance carrier or other health benefit plan providing my coverage (including, but not limited to, any employer, employer group or trust sponsored or offered plan) to pay Shane Retina directly for the services that Shane Retina provided during this visit. In return for the services rendered and to be rendered by Shane Retina, I hereby irrevocably assign and transfer to Shane Retina, all right, title, and interest in all benefits payable for the healthcare rendered, which are provided in any and all insurance policies and health benefit plans for which I am entitled services or I am entitled to recover. I understand that any payment received from these policies and/or plans will be applied to the amount that I have agreed to pay for services rendered during this visit, as furthered described under Section 2. This assignment shall be for the purpose of granting Shane Retina an independent right of recovery against my insurer or health benefits plan, but shall not be construed as an obligation of Shane Retina to pursue any such right of recovery. In no events will Shane Retina retain benefits in excess of the amount owed to Shane Retina for the care and treatment rendered during the admission. If a third-party payer (such as an insurance company or employer group or trust-sponsored or offered plan) may be obligated to pay some or all of these charges, I agree to take all actions necessary to assist Shane Retina in collecting payment from any such third-party payer. I hereby appoint Shane Retina as my authorized representative to pursue, if it so choose, all administrative remedies, clams and/or lawsuits on my behalf and, at the election of Shane Retina, against any responsible third party, medical insurer, or employer-sponsored medical benefits plan for purposes of collecting any and all benefits due me for the payment of the charges referred to in Section 2 above. If Shane Retina elects to pursue a claim or lawsuit against a third-party payer as authorized representative, I agree to execute a special power of attorney, if requested, authorizing Shane Retina, to take all actions necessary or appropriate in pursuit of such claim or lawsuit, including allowing Shane Retina, to bring suit against the third-party payer in my name. I agree to pay over to Shane Retina immediately all sums recovered in any claims or lawsuit brought on my behalf by Shane Retina (up to the amount of the charges from Shane Retina, P.A, plus expenses and attorney’s fees).
5) MEDICARE/MEDICAID PATIENT CERTIFICATION AND ASSIGNMENT OF BENEFIT
I certify that if I am a Medicare or Medicaid patient the information given by me and applied under TITLE XVIII of the Social Security Act or TITLE XIX (Medicaid) is correct. I further authorize Shane Retina or its employees to
release to Social Security Administration or State of Florida, or its intermediaries any and all information needed to process this or any other Medicare-related claim. I request and assign that payment of all authorized benefits be made on my behalf to Shane Retina I understand that I am personally and fully responsible for any non-covered services, denied services, health insurance deductibles, and co-insurance payments. In addition, subsequent rejection of Medicare and/or Medicaid claims, as a result of enrollment in an HMO, will constitute responsibility for payment on my part.
6) HMO/PPO/MEDIPASS MANAGED CARE PARTICIPATION
I understand that if I am a member of an HMO/PPO/MEDIPASS or other Managed Care Organization, I am responsible for obtaining the required authorization and referrals as mandated by my Managed Care Organization to receive care from this facility and its providers. I further acknowledge that if I choose to receive services at this facility without proper authorization from my Managed Care Organization, I will be fully responsible for payment of my bill. I realize that it is
my responsibility as the patient to know whether a services, procedure, and/or test, etc. is covered by my Managed Care Organization. (As the patient, I may contact my Managed Care Organization to appeal their decision not to authorize services.)
7) GUARANTOR AGREEMENT
By signing as Patient/Parent/Guardian or Guarantor, spouse or agent of the aforementioned parties, I hereby agree that any and all charges that arise within the treatment, past or future treatment if related to the incident or condition giving rise to this visit or service, not covered by any insurance, program, sponsorship, or other third-party coverage I may have are due and payable by me at the time of the visit or service. I hereby acknowledge that Shane Retina has agreed to bill my insurance or other third-party carrier and has agreed to do so as a courtesy, and Shane Retina has the right to demand payment in full from me at any time prior to full payment from any insurance carrier or third party unless it is contractually stated that I will not be billed. I hereby acknowledge that I have been told, prior to receiving treatment, that I may be billed by Shane Retina
8) FAILURE TO FOLLOW PHYSICIAN'S ORDERS
I, as the patient, am expected to comply with a physician’s orders to manage medical disease and/or symptoms. In the event that I do not follow physician’s orders, the physician shall be released from any injury or illness claim resulting from my failure to follow orders, and I may be discharged from the clinic. Not following physician orders includes, but is not limited to, missing follow-up appointments, as well as missing or postponing or refusing additional tests or treatments which may rule out/confirm/discover/treat illness.
9) MISSED APPOINTMENTS
I am expected to notify Shane Retina at least two days in advance of the need to cancel or reschedule an appointment. Two missed appointments within a 6-month period without the above notification may incur a warning letter, followed by dismissal from the practice for a third violation.
