General Medical Information Form (Page 2 of 4) in pdf

Patient Authorization for ePRESCRIBE

ePrecribing is a physician's ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy

from the practice. ePrescribing greatly reduces medication errors and enhances patient safety. Understanding all of the above, I

hereby authorize the physician and/or staff of INTERNAL MEDICINE AND PEDIATRICS OF WEST MICHIGAN to enroll me in the

ePrescribe Program. .

Patient signature ____________________________________________

Date ___________________________

Patient Authorization for PHARMACY BENEFITS MANAGER

I authorize the physician and/or staff of INTERNAL MEDICINE AND PEDIATRICS OF WEST MICHIGAN to request and obtain my

prescription medication history from other healthcare providers, the pharmacy benefit manager and/or any third party pharmacy payors

for treatment purposes.

Patient signature ____________________________________________

Date ___________________________

Patient Authorization for MEDICARE PATIENTS

I authorize the physician and/or staff of INTERNAL MEDICINE AND PEDIATRICS OF WEST MICHIGAN to release to the social

security administration, Health Care Financing Administration or its intermediaries or carriers any information needed for this or any

Medicare claim. I permit a copy of this Authorization to be used in place of the original and request payment of medical insurance

benefits either to myself or to the party who may cause Medicare payment information to cross over automatically to my supplement

insurer. I understand that I am financially responsible for any services deemed non-covered by Medicare.

Patient signature ____________________________________________

Date ___________________________

Patient Authorization for PPO and HMO PATIENTS

I authorize the physician and/or staff of INTERNAL MEDICINE AND PEDIATRICS OF WEST MICHIGAN to release to my insurance

company or its representative any information including the diagnosis and records of any treatment or examination rendered to me

during medical or surgical care. I authorize and request my above named insurance company to pay directly to Rheumatology

Specialists of New Mexico, LLC the amount due for medical or surgical services. I understand that I am financially responsible for any

services deemed non-covered by my insurance company.

Patient signature ____________________________________________

Date ___________________________

Patient Authorization for ALL PATIENTS

I understand that I am financially responsible for services in the office and that refunds from services charged on a credit card will be

returned to the same credit card. Furthermore, I also understand that any account balance that is not paid may be sent to a collection

agency. Should any delinquent account balance be referred to a collection agency, I understand that I will be financially responsible

for any and all cost and fees relating to the collection of my debt. I also authorize my physician and INTERNAL MEDICINE AND

PEDIATRICS OF WEST MICHIGAN to photograph me for medically related documentation purposes.

Patient signature ____________________________________________

Date ___________________________

Special Accommodations

If a patient requires an accommodation for their appointment, the individual or his/her representative must notify INTERNAL MEDICINE

AND PEDIATRICS OF WEST MICHIGAN of the needed accommodation one week prior to the first new patient appointment.

Subsequent appointments also require one week’s notice. Under the American with Disabilities Act, “Providers are responsible for

incurring all costs of providing reasonable aid and cannot pass that charge onto the patient or to his/her insurance company.” If a

patient who has requested accommodations does not provide a minimum of 24 hours’ notice to cancel the appointment or does not

show to the scheduled appointment, all charges incurred by INTERNAL MEDICINE AND PEDIATRICS OF WEST MICHIGAN is the

patient’s responsibilities.

Patient signature ____________________________________________

Date ___________________________

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

Notice to patients: We are required to provide you with a copy of our Notice of Privacy Practices which states how we may use and/or

disclose your health information.

Please sign this form to acknowledge receipt of the notice.

You may refuse to sign the

acknowledgement, if you wish. I acknowledge that I have received a copy of the INTERNAL MEDICINE AND PEDIATRICS OF

WEST MICHIGAN’S Notice of Privacy Practices.

____________________________________

_________________________________________

_______________

Printed name

Signature

Date signed

General Medical Information Form Page 2

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