RIDGE LINE ENDOSCOPY CENTER
CONSENT FOR TREATMENT AND FINANCIAL RESPONSIBILITY
As either the Patient or the legally authorized representative of the Patient, the following consents, understandings, and agreements are made on my behalf or on behalf of the Patient in partial consideration of the health care services to be provided to the Patient by RIDGELINE ENDOSCOPY CENTER. This consent document will be in effect and apply to all services (including future services) provided by RIDGELINE ENDOSCOPY CENTER. If a new consent document is signed, the terms of the new document will apply to services received from the date the new document is signed.
CONSENT FOR SERVICES
On behalf of the Patient, consent is hereby given to RIDGELINE ENDOSCOPY CENTER, its medical staff, and employee , to provide health care services to Patient.
RELEASE OF INFORMATION
The law requires RIDGELINE ENDOSCOPY CENTER to make and keep records of your medical treatment. RIDGELINE ENDOSCOPY CENTER safeguards those records. Access to medical records is limited to persons who are providing, coordinating, evaluating, or improving health care, and to persons who are involved in maintaining medical records, subject to applicable law. By receiving services at RIDGELINE ENDOSCOPY CENTER, you agree to the release of medical record information for the uses specified above. You also agree to release claims related information to insurance companies or other third parties to assist in paying your health care costs. You also have the right to access your medical record. There will be a charge for copies of your medical record. I understand that RIDGELINE ENDOSCOPY CENTER is given thirty days to process my request for access if my information is maintained on site, and sixty days if maintained off site.
ASSIGNMENT OF BENEFITS
Any and all benefits from insurance companies and other third party payors that are payable to Patient or are paid on behalf of Patient for health care services and related payments for services rendered or provided to Patient are hereby transferred and assigned to RIDGELINE ENDOSCOPY CENTER for the exclusive purpose of paying for charges associated with health care services provided to the Patient. It is understood and intended that all insurance companies and other third party payors will pay benefits directly to RIDGELINE ENDOSCOPY CENTER in payment of the charges for the health care services provided to Patient. If insurance company’s payment is not made directly to RIDGELINE ENDOSCOPY CENTER, patient shall remit insurance company’s payment and Explanation of Benefits to RIDGELINE ENDOSCOPY CENTER within 10 calendar days of receipt of payment.
Patient and the undersigned, if other than the Patient, each jointly and severally agree to pay for all the health care services rendered to Patient at RIDGELINE ENDOSCOPY CENTER, including but not limited to any amounts not paid by insurance company or other third party payor. Please note that Ridgeline does not do the billing for the physician services or lab fees that may incur during your procedure. The Patient is responsible to contact these providers to work out payment arrangements for these services. Patient and the undersigned, if other than the Patient, remains responsible for all co-payments, deductibles, co-insurance, denied services, and/or non-covered services regardless of the amount paid by insurance or third party payor. It is understood and agreed that charges that are not paid in a timely fashion may be placed for collection. It is further understood and agreed by the Patient and the undersigned that any amounts not paid within 60 days of patient responsibility will be managed by a third party billing service. In the event that any unpaid balance is placed for collection or with an attorney for purposes of collection, I Patient or undersigned, if other than the Patient, each jointly and severally agree to pay costs and reasonable attorney’s fees in connection with the collection process. A service charge of $20.00 may be collected in connection with any check or other instrument tendered by me but returned unpaid to RIDGELINE ENDOSCOPY CENTER
DISCLOSURE OF OWNERSHIP
The physician who referred you to RIDGELINE ENDOSCOPY CENTER may have an ownership interest in this facility. You are free to choose another facility in which to receive services.
It is agreed that the patient will be responsible for obtaining any referral required by any insurance carrier, including referral from a managed care provider or primary care physician, to ensure proper reimbursement from said insurance carrier.
MEDICARE/MEDICAID PATIENTS CERTIFICATION
I certify that the information given by me in applying for payment under Titles XVII and XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers or to the State any information needed to process a claim for this or any related service. I request that payment of authorized charges be made in my behalf direct to RIDGELINE ENDOSCOPY CENTER for its charges of physician or other providers for whom RIDGELINE ENDOSCOPY CENTER is authorized to bill in connection with its service.
I request payment of authorized benefits to RIDGELINE ENDOSCOPY CENTER on my behalf for any services furnished me by RIDGELINE ENDOSCOPY CENTER, including physician services. I authorize any holder of medical or other information about me to release to CHAMPUS/CHAMPVA and its agents any information needed to determine these benefits or benefits for any related service. The undersigned signs this document either as the Patient or as the agent or representative of the Patient authorized to execute this document and to accept and agree to its terms on behalf of the Patient. I have read the foregoing and have had the opportunity to ask any questions I may have about the foregoing. Such questions have been answered to my satisfaction and I understand what I am agreeing to by signing below. I understand that I am entitled to request and obtain a copy of this document.