Patient Information Care Sheet (Page 2 of 2) in pdf

Northwest Health Care Associates

Authorization for payment and insurance information

Consent for Release and Use of Confidential Information

Receipt of Notice of Privacy Practices Form

I understand that payment and/or current insurance information is required at the time of service. I assign all

rights and claims for reimbursement of expenses allowable under my insurance plan and authorize payment

directly to Northwest Health Care Associates for services and/or treatments rendered. I understand that

Northwest Healthcare Associates does not accept responsibility for collecting my insurance claims or for

negotiating a settlement on disputed claims. I understand that I am responsible for charges not covered by my

medical insurance plan(s). If my account exceeds 60 days without payment or arrangement, my account will be

considered delinquent and can be subject to legal action and/or assignment to a collection agency.

I voluntarily give my consent to care and treatment as prescribed by the physician(s) as is necessary in his/her

medical judgment. I hereby give my consent to Northwest Healthcare Associates to use or disclose, for the purpose

of carrying out treatment, payment, or Health care operations, all information contained in the patient records as

described below.

I acknowledge receipt of the practice’s Notice of Privacy Practices. This notice provides detailed information about

how the practice may use and disclose my confidential information.

I understand that the practice has reserved a right to change its’ privacy practices that are described in the notice. I

also understand that a copy of any revised notice will be provided to me or made available upon request or at the

time of subsequent office visits.

I understand that this consent is valid until it is revoked, in writing, by me. I also understand that I will not be able

to revoke this consent in cases where the practice has already relied on it to use or disclose my health information.

Written revocation of consent must be sent to Northwest Healthcare Associates.

Patient Name: (Please Print Clearly) ________________________________________________________________

Signed:

___________________________________________

____________________ Date________________

(Relationship)

Patient Information Care Sheet Page 2