Hipaa Registration Form Guarantor Information (Page 3 of 3) in pdf

My signature below authorizes Palmetto Primary Care Physicians to release any medical information necessary to process my or my dependent's insurance

claim.  

I authorize any benefits due be paid directly to Palmetto Primary Care Physicians.

Your insurance company only provides our office an "estimate" of covered benefits prior to receiving any services or materials from us. This "estimate" is not a guarantee of

benefits.  

I understand that I may be required to pay a deductible, co-pay or co-insurance for covered services, as well as any balance for services not covered by my insurance plan. In

the event that my insurance does not cover for services and/or materials rendered to me, I agree to be responsible for payment of all balances on my or my dependent's

behalf for those services and/or materials not covered by insurance. I understand that all fees for professional services shall be paid at time of service and are NON-

REFUNDABLE. Any returned check will incur a $35 fee.

Please initial each line below to acknowledge practice policies:

I understand I may be charged a fee for missing an appointment without 24 hr advance notification to cancel

I understand I may be charged a fee for any forms or paperwork to be completed by the physician

I certify that I have read and understand the above information to the best of my knowledge.

______________________________________________________________

________ / ____________ / _____________

Patient or Guarantor Signature

Date

Consent to Obtain Pharmacy Information Electronically

Palmetto Primary Care Physicians (PPCP) currently participates in the Surescripts system. This allows for the electronic prescribing of medications, which provides a

convenience to patients and physicians and also reduces medication error. An additional portion of this service allows for the electronic receiving of medication information

such as medications, dosages and prescriptions filled from participating pharmacies. This too, reduces error in medication entry into the medical record and provides your

physician with an up-to-date medication profile.

By signing below, you give PPCP permission to access your information to receive this information electronically for your medical record.

Primary Pharmacy (Name, Street, City and State):

_________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

Print Patient’s Name: ___________________________________________________________

Signature: _____________________________________________________________________

Date: _______________________

Hipaa Registration Form Guarantor Information Page 3

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