I consent for Texas Lung Care Associates to access my prescription medication history and access to my medical records regarding current/past medical conditions and to administer treatments, tests, and/or diagnostic tests to treat my injury/illness on an outpatient basis. I acknowledge there is no guarantee as to the outcome of any treatment received.
I authorize Texas Lung Care Associates to discuss my care, not limited to medical needs, treatment, and payment options with the following persons:
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
I, the undersigned, authorize TLC to send/receive confidential healthcare information as that term is defined by HIPPA (Health Insurance Portability and Accountability Act of 1996, 45 C.F.R., Parts 160-164) by facsimile to healthcare providers, hospitals, laboratories, and other medical caregivers in the necessary coordination of care for the patient listed below.
I may revoke this authorization by giving TLC five (5) days written notice. This revocation may be facsimile transmission: however, a written copy of the revocation must be mailed to TLC as well.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
We are committed to providing you with quality care, and your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your responsibilities as our patient. It is your responsibility to contact our office to notify us of any changes to your information, such as a change in address, telephone number, or insurance information.
You must complete and sign our Patient Financial Policy before care is rendered.
Credit Card on File Policy: All patients will be asked to have a credit, debit or HSA card saved on their account. This card will be stored securely and in an encrypted manner. After your insurance company has processed all charges, we will charge the account the remaining balance you owe, if any, and email you a receipt for your records. If there is a credit due to you, we will refund this amount to the original card used. You have the option to ask us to contact you for balances greater than $250 to confirm payment arrangements before charging your card.
Please provide us with your current insurance information at the time of scheduling each visit and notify us of any changes. We must be able to verify your eligibility prior to your visit or your appointment may be rescheduled. We will scan a copy of your insurance card and photo ID to copy and keep on file for our records in accordance with insurance plan requirements.
Your health insurance policy is a contract between you and your health insurance company. Please note it is your responsibility as the Policy holder/Patient to understand the coverage and benefits and be knowledgeable of any deductibles, copayments and/or coinsurance.
It is the patient’s responsibility to be sure your doctor is in network, and the services are covered under your plan. If your doctor is out-of- network, you will have a higher out of pocket cost. If your insurance requires a referral, it is your responsibility to provide the referral to our office prior to seeing the physician. If unable to provide the referral prior to the visit payment in full will be required at the time of the visit. If you have any questions regarding your current insurance policy benefits you should contact your insurance plans’ Member Services.
Nonpayment. Please be aware that if a balance remains unpaid without partial payments, we may refer your account to a collection agency, and you may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.
Financial Hardship & Payment Plan. If other arrangements need to be made, please speak with the receptionist prior to your visit.
Assignment of Benefits. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance, and other health plans. I authorize any insurance company to pay benefits due directly to Texas Lung Care Associates and to release to my insurance carrier any medical records or documents requested to secure payment. This assignment will remain in effect until revoked by me in writing.
Medicare Release & Assignment of Benefits. I authorize any holder of medical or other information about me to be released to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or related Medicare claim. I permit a copy of this request for payment of medical insurance benefits either to myself or the party who accepts assignment.
I understand the Patient Financial Policy of Texas Lung Care Associates and I agree to be bound by its terms. I agree that I am financially responsible for all charges.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it Carefully.
Protected health information about you is obtained as a record of your contacts or visits for healthcare services with TEXAS LUNG CARE. This information is called protected health information. Specifically, "Protected Health Information" is information about you, including demographic information (i.e., name, address, phone, etc.) that may identify you and relate to your past, present or future physical or mental health condition and related health care services.
TEXAS LUNG CARE is required to follow specific rules on maintaining the confidentiality of your protected health information, how our staff uses your information, and how we disclose or share this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your protected health information. It also describes how we follow those rules and use and disclose your protected health information to provide your treatment, obtain payment for services you receive, manage our health care operations and for other purposes that are permitted or required by law.
If you have any questions about this Notice, please contact our administrator at 817-886-8552
Your Rights Under The Privacy Rule
Following is a statement of your rights, under the Privacy Rule, in reference to your protected health information. Please feel free to discuss any questions with our staff.
You have the right to receive, and we are required to provide you with a copy of this Notice of Privacy Practices- We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. If needed, new versions of this notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in mail or ask for one at the time of your next appointment.
You have the right to authorize other uses and disclosures. This means you have the right to authorize or deny any other use or disclosure of protected health information not specified in this notice. You may revoke authorization, at any time, in writing, except to the extent that your physician or our office has taken an action in reliance on the use or disclosure indicated in the authorization.
You have the right to designate a personal representative- This means you may designate a person with delegated authority to consent to or authorize the use or disclosure of protected health information.
You have the right to inspect and copy your protected health information - This means you may inspect and obtain a copy of protected health information about you that is contained in your patient record.
You have the right to request a restriction of your protected health information- This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. In certain cases, we may deny your request. For a restriction.
You may have the right to have us amend your protected health information - This means you may request an amendment of your protected health information for as long as we maintain this information. In certain cases, we may deny your request for an amendment.
You have the right to request a disclosure accountability - This means that you may request a listing of your protected health information disclosures we have made to entities or persons outside of our office.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Manager of your complaint.
How We May Use or Disclose Protected Health Information
The following are examples of use and disclosures of your protected health care information that we are permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.
For Treatment- We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that is involved in your care and treatment. For example, we would disclose your protected health information, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose protected health information to other physicians who may be involved in your care and treatment.
We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care. And we may contact you to provide information about health-related benefits and services offered by our office.
For Payment -Your protected health information will be used, as needed, to obtain payment for our health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as deciding of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.
For Healthcare Operations- We may use or disclose, as-needed, your protected health information in order to support the business activities of our practices. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, and auditing functions. It also includes Education, provider credentialing, certification, underwriting, rating, or other insurance related activities. Additionally, it includes business administrative activities such as customer service, compliance with privacy requirements, internal grievance procedures, due diligence in connection with the sale or transfer of assets and creating de-identified information.
Other Permitted and Required Uses and Disclosures
We may also use and disclose your protected health information in the following instances. You can agree or object to the use or disclosure of all or part of your protected health information.
To others Involved in Your Healthcare- Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person, you identify your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, general condition or death. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
As Required by Law- We may use or disclose your protected health information to the extent that the use or disclosure is required by law.
For Public Health- We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.
For Communicable Diseases- We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
For Health Oversight- We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.
In Cases of Abuse or Neglect- We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
To The Food and Drug Administration- We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
For Legal Proceedings: We may disclose protected health information during any judicial or administrative proceedings, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process
To Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes.
To Coroners, Funeral Directors, and Organ Donation- We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, to permit the funeral director to carry out their duties. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
In Cases of Criminal Activity- Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
For Military Activity and National Security- When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities: (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.
For Worker's Compensation- Your protected health information may be disclosed by us as authorized to comply with worker's compensation laws and other similar legally established programs.
When an Inmate- We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information while providing care to you.
Required Uses and Disclosures- Under the law, we must make disclosures about you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the Privacy Rule.
ACKNOWLEDGE OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that TLC has provided a copy of Texas Lung Care "Notice of Privacy Practices". This notice describes how TEXAS LUNG CARE may use and disclose my protected health information, certain restrictions on the use and disclosure of my health information, and rights I may have regarding my protected health information.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Please sign your name in the area below