I. CONSENT TO TREAT
I authorize The Plastic Surgery Group, PC and Hayes Hand Center which is a division of The Plastic Surgery Group, its health care practitioners, staff, office surgery facility and other individuals involved in my care to examine me and perform any tests, procedures and/or treatments that may be helpful to care for my injury or illness.
I understand that The Plastic Surgery Group, PC and Hayes Hand Center is dedicated to teaching, that authorized resident physicians my observe and assist in diagnosis, treatment and care, and that photographs may be taken for purposes of diagnosis, teaching and documentation. I reserve the right to give specific permission for publication of any picture that personally identifies me.
II. PAYMENT AND FINANCIAL OBLIGATIONS
I request that payment of authorized Medicare and/or other insurance company benefits be made to The Plastic Surgery Group, PC / Hayes Hand Center for any services furnished to me my that physician/supplien I authorize any holder of medical information about me to release to Medicare and/or other insurance companies and its agents any information needed to determine benefits of the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare and/or other insurance company assigned cases, the physician or supplier agrees to accept the charge determined of the Medicare and/or other insurance company as the full charge, and the patient is responsible only for the deductible, coinsurance and non-covered insurance services. Coinsurance and the deductible are based upon the charge determination of the Medicare and/or other insurance company.
I understand that I am responsible for paying all charges associated with this treatment. If I have health insurance, I understand thatI am financially responsible in the event that all or some payment is denied by my insurance carrier or other third party who is responsible for payment. I am also responsible for those charges not covered by my insurance such as deductibles, co- paysor evaluation or treatment that are not included as an insurance benefit. I understand that if my insurance plan requires a referral,prior authorization for surgery and/or a second surgical opinion and this has not been obtained, I am responsible for payment of services rendered.
I authorize my health insurance carrier(s) or other third parties who are responsible for paying for my health care to pay costs associated with my evaluation and care directly to The Plastic Surgery Group, PC / Hayes Hand Center.
I authorize the release of any medical information necessary to process this claim. I realize that in the event these claims are denied I am responsible for payment. I authorize my private health insurance carrier to reimburse The Plastic Surgery Group, PC / Hayes Hand Center in the event that Workers' Compensation denies payment. My carrier's failure to pay does not release me from this responsibility. I also agree that should this account be turned to collection, I will be responsible for all costs associated with debt collection, including attorney fees and court costs.
III. CONSENT TO USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I consent to The Plastic Surgery Group. PC / Hayes Hand Center, its health care practitioners, staff and other individuals, use and disclosure of my protected health information ("PHI") in support of my diagnosis and treatment, payment for themedical services I receive, and the legitimate health care operations of the medical practice. I consent to The Plastic Surgery Group, PC / Hayes Hand Center disclosure of PHI to other health care practitioners and facilities that are involved in providing medical services to me.