Assignment of Benefits - Financial Agreement

I hereby give lifetime authorization for payment of insurance benefits to be made directly to Cape Family Medical Clinic, and any assisting physicians, for services rendered. I understand that I am financially responsible for all charges whether they are covered by insurance. In the event of default, I agree to pay all costs of collection, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.

Notice of Privacy Practices

This policy is developed in compliance with the Health Insurance Portability and Accountability Act of 1996 (45 CFR) (HIPAA). If you are a client of Cape Family Medical Clinic (CFMC), this notice describes how your health information may be used and disclosed, and how you can get access to this information. Please review this notice carefully. A full copy of this notice is available upon request.

1. Understanding Your Health Information

As a client of Cape Family Medical Clinic, a record is kept of your visit. This record, typically referred to as a patient record, contains your reason for seeking services, symptoms, diagnosis, and plan of treatment for future services. Although the case record is the property of CFMC, the information within the record belongs to you. This information is considered your “Protected Health Information” (PHI) and is afforded certain protections under the law.

2. How We Can Use Your Health Information

• Service
• Emergencies
• Payment
• Health Care Operations
• Duty to Warn
• Charges Against the Clinic
• Public Health
• Requirements by law
• Private Support
• Other with notification

CFMC will release only the minimum amount of information necessary to address the purpose of the use or disclosure. In any other situation, CFMC will request your written authorization before using or disclosing any of your identifiable health information. If you choose to sign such an authorization to disclose information, you can revoke that authorization at any time to stop future uses/disclosures if you do so in writing to CFMC.

3. Your Rights Regarding Your Health Information

You have the following rights with respect to your protected health information:

• Request in writing that your protected health information not be used or disclosed by CFMC for treatment, payment, or administration purposes or to persons involved in your care except when specifically authorized by you. The clinic will consider your request, but we are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.
• Request that we contact or send you information at an alternative address or by an alternative means. We will agree to your request if it is reasonably easy for us to do so.
• Inspect and copy your protected health information. Any such requests must be made in writing. The clinic will respond in writing to such a request within 30 days. If you request copies, CFMC may charge you a reasonable cost for copying.
• Submit a request to amend your information if you believe that information in your record is incorrect or if important information is missing.
• An accounting of disclosures of your protected health information. You have a right to receive this Notice in paper and/or electronic format.

4. The Clinic’s Duties

CFMC is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information. CFMC is required to abide by the terms of this Notice currently in effect, and CFMC reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that it maintains. Should the clinic make changes in its Notice, it will post the changed Notice in its office waiting areas and on our website. You may request a copy of the Notice at any time.

5. Complaint Procedure

If you believe your privacy rights have been violated, you may file a complaint with Cape Family Medical Clinic’s Privacy Official or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing directly to Cape Family Medical’s Privacy Official. Cape Family Medical Clinic assures you that there will be no retaliation for filing a complaint. You will not be retaliated against for filing any complaint. To file a complaint with Cape Family Medical Clinic Services:

Cape Family Medical Clinic C/O Privacy Official 24 North Sprigg Street Cape Girardeau, MO 63701 (Office) 1-573-332-7992

Consent for Treatment & Authorization for Release of Information & Payments

In consideration of the services to be rendered to this patient, I agree to pay this account for this occasion of service at Cape Family Medical Clinic in accordance with its regular rates and charges for services and goods at the time rendered. Delinquent accounts shall bear interest at the maximum legal rate. Should the account become delinquent and be referred to a collection agency or attorney I shall pay all collection expenses, court costs and attorney fees.

Many insurance companies require pre-certification of treatment by the patient. Cape Family Medical Clinic will attempt to assist you; however, we strongly recommend you contact your carrier in this regard. It is your responsibility to provide our clinic with timely notification of your insurance coverage. We will not be liable for any penalties or reductions in payment regarding pre-certification requirements.

CONSENT OF TREATMENT: The undersigned hereby consents to emergency and/or standard treatment and other routine medical and nursing procedures. I understand this may include, but is not limited to X-ray procedures, local anesthesia, and laboratory tests, measurements, and procedures.

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Cape Family Medical Clinic to release any and all information contained in my medical records pertaining to the period of treatment to my family physician or consulting physician or to other healthcare professionals involved in my care to my insurance company and third party carriers, or their representatives, as necessary to settle this account and to any agencies that are needed to assist in my care.

AUTHORIZATION FOR PAYMENT OF BENEFITS: I hereby authorize Cape Family Medical Clinic or medical insurance benefits otherwise payable to me for services rendered but not exceed the balance due of the regular charges provided to me for and during this period of treatment. I understand that I am financially responsible to the clinic for charges not covered by this authorization. I permit a copy of this authorization to be used in place of the original and direct payment of medical insurance benefits directly to Cape Family Medical Clinic.