Patient Consent & Financial Policies

Patient Consent and Financial Policies

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services, my private insurance, and their agents any protected health information (PHI) or individually identifiable health information (IIHI) needed to determine benefits for related healthcare services. Please refer to TRS Health’s Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent.

CONSENT TO BILL, ASSIGNMENT OF BENEFITS, AND PAYMENT
I authorize TRS Health to submit claims to my insurance carrier for the medical services provided by TRS Health. My insurance company, in lieu of reimbursing me directly, will pay to TRS Health any benefits for services rendered. I understand that the amount billed to my insurance provider will be a standard rate negotiated and contracted by TRS Health and my insurance company. I agree to pay for services that are not covered or for charges not paid in full, including but not limited to co-payments, co-insurance, deductibles, or charges not covered by insurance.

FINANCIAL ASSISTANCE
For patients with financial need, we offer extended payment plans or financial assistance programs. Please speak with one of our Patient Care Specialists to discuss available options.

ASSIGNMENT OF BENEFITS
I understand that TRS Health reserves the right to review all agreements on an individual basis to determine continued acceptance of assignment for Medicare and/or other insurance providers. If my insurance provider determines that medical necessity no longer exists, I understand that any future services may not be covered, and I may be responsible for the costs of those services.

ACKNOWLEDGMENTS
I acknowledge receipt and understanding of my Patient Bill of Rights and the Notice of Privacy Practices, which I received as part of my care, and understand that I may also view a copy of these documents at www.trshealth.org. I also acknowledge that I have received and/or will receive information on any follow-up services from TRS Health. In addition, I agree that TRS Health may contact me in the future via telephone, email, instant messaging, mail, or other means of communication regarding appointments or healthcare follow-ups.

Note: If the patient is physically or mentally unable to sign, a representative may sign on the patient’s behalf. In addition, the representative’s signature, date signed, representative’s name (print), address, relationship to the patient, and reason why the patient cannot sign must be documented.

I understand that I may revoke this consent in writing; however, my revocation will not apply to information already used or disclosed in reliance on this consent. I agree that a copy of this consent may be used in place of the original. I also understand that by refusing to sign this consent or by revoking it, TRS Health may not be able to provide services to me.

My signature on the Patient Consent Form indicates that I understand and accept the content of this document.