Common use of Missed Appointments Clause in Contracts

Missed Appointments. We understand that unforeseen events happen that may prevent a patient from making his/her appointment; however patients will be charged a non-refundable $25.00 no-show fee after his/her second missed appointment. To avoid this fee, kindly call 24 hours prior and cancel or reschedule any appointment(s). As a courtesy, patients will receive a reminder phone call from our office the business day prior to his/her appointment. I have read the Patient Financial Policy and agree to abide by its terms. I authorize my insurance company to forward the Explanation of Benefits (EOB) and related payments to Xxxxxx X. Xxxx, M.D. Patient Signature Date INTERNAL MEDICINE GROUP OF TAMPA BAY ID# ***UPDATED OFFICE POLICIES*** Effective January 1, 2014 As part of our ongoing efforts to make your experience with us a pleasant one, and to ensure your continued satisfaction with our services, we have adopted some additional office policies. Please read carefully, and initial the following updates. Feel free to speak with our staff should you have any questions or concerns about these policies. Blood work is required before all physical exams. If a patient misses a pre- physical blood work appointment, their physical exam will be canceled, and will need to be rescheduled. Payment for any required insurance co-pay, self-pay charge, and/or any outstanding balance on a patient’s account will be required at time of visit. A $25.00 non refundable no show fee will be applied to the patient’s account for an appointment missed without a 24 hour notice to cancel. This fee is not covered by insurance. It is the sole responsibility of the patient. As a consideration to other patients, patients who are 20 minutes or more late for their appointment will be rescheduled to another time. All prescription requests require a minimum 24 hour turnaround time for processing. Thank you for your cooperation. We look forward to your continued care with us. Patient’s Name: Patient’s Signature: Date: Witness Signature: Date: _ INTERNAL MEDICINE GROUP OF TAMPA BAY ***INSURANCE COVERAGE NOTICE*** I, understand that the following may not be covered by my insurance; laboratory testing, including but not limited to Labcorp, Quest Diagnostics, ECG/EKG, vaccinations, and/or injection therapy. I understand I will be responsible for 100% of the billed cost for any of the above tests/procedures not covered by my insurance. I also understand that it is my responsibility as the patient, and the policy holder to contact my insurance company to inquire as to what services are covered. I also understand that any lab work done at INTERNAL MEDICINE GROUP OF TAMPA BAY invoice(s) I receive for lab fees are from the lab directly, therefore all billing issues need to be addressed with the lab directly. I as a patient of Internal Medicine Group of Tampa Bay understand that my physical exam must be scheduled a year and a day from my last physical in order for the exam to be covered by insurance. I also understand that it is my responsibility to confirm the date of my last physical exam before scheduling. If my appointment is scheduled before the one year and one day required by my insurance, I understand that I will be financially responsible for the appointment and all services provided. _____________________________________________________ _________________ Patient Signature Date Witness Signature Date 00000 Xxxxx Xxxxx Xxxx Xxxxx X Xxxxx, XX 00000 Phone: (000) 000-0000 Fax: (000) 000-0000 INTERNAL MEDICINE GROUP OF TAMPA BAY *PERMISSION TO RELEASE PROTECTED MEDICAL INFORMATION* The doctor and staff at INTERNAL MEDICINE GROUP OF TAMPA BAY cannot discuss your protected health information (PHI) with anyone other than yourself unless you authorize us to do so. Please list below the names(s) of the individual(s) you authorize our office to discuss your care with. Your PHI will be disclosed to the individual(s) listed below until you notify us otherwise in writing. This authorization will remain in effect for one year unless otherwise specified. I understand by signing this form I authorize the release of all medical records, which may include psychiatric information, genetic counseling (Acquired Immunodeficiency Syndrome), and/or may include the result of an HIV test. I understand that my (PHI) may be used or disclosed under this authorization, and may be subject to re-disclosure, thus my PHI may no longer be protected by law. By signing this authorization I expressly consent to the release of information as designated above. I understand I must notify INTERNAL MEDICNE GROUP OF TAMPA BAY, in writing, where the original authorization is retained, in order to discontinue this consent to release. I, give my permission for the following person (s) to receive my medical information. Name: Relationship: Signature Date INTERNAL MEDICNE GROUP OF TAMPA BAY I, authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to contact me by home phone, cell phone, fax, and/or email, and leave detailed messages regarding all test results, and/or reminders for future scheduled appointments. Patient Home Phone # Patient Cell Phone # Patient Private Fax # Patient email address If there are any changes to the contact information previously provided to INTERNAL MEDICINE GROUP OF TAMPA BAY I understand that it is my responsibility to provide timely updates to my contact information on file. If I wish to update any information, or revoke permission for messages to be left regarding test results, I must contact INTERNAL MEDICINE GROUP OF TAMPA BAY in writing during normal business hours. Please initial below to indicate your authorization Yes I authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to leave messages. No I do not authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to leave messages. Signature Date Print Name INTERNAL MEDICINE GROUP OF TAMPA BAY PRIVACY NOTICE Effective January 1, 2014 A copy of INTERNAL MEDICINE GROUP OF TAMPA BAY'S Privacy Practices is available at xxx.xxxxxxxxxxx.xxx or at our office. Acknowledgment of receipt of Notice of Privacy Practices: I, have received notice of Privacy Practices from INTERNAL MEDICINE GROUP OF TAMPA BAY which has been updated for the new Omnibus Rule and has an effective date of September 23, 2013. We encourage you to review it carefully. Our notice of Privacy Practices is subject to change. If we change our Notice, you may obtain a copy at the front desk. The notice describes: • the ways the Privacy Rule allows our practice to use and disclose protected health information. How our practice will get your permission, or authorization, before using your health records for any other reason. • the practice's duties to protect health information privacy. • the patient's privacy rights, including the right to complain to HHS and to the covered entity if you believe your privacy rights have been violated. • how to contact our practice for more information and to make a complaint. I understand that the Privacy Practices may be revised from time to time and that I have the right to receive an updated copy upon request.

Missed Appointments. We understand In the event that unforeseen events happen that may prevent you are unable to keep a patient from making his/her scheduled appointment; however patients , it is your responsibility to notify me with no less than 24-hour notice or you will be charged liable for the full session fee of $160. If your appointment is scheduled for a non-refundable Monday, you must cancel before Sunday or the $25.00 no-show 160 fee after his/her second missed appointment. To avoid this fee, kindly call 24 hours prior and cancel or reschedule any appointment(s). As a courtesy, patients will receive a reminder phone call from our office the business day prior to his/her appointmentapplies. I have read collect payment and schedule your next appointment at the Patient Financial Policy end of our 50-minute session. My fees for sessions and services are: • 50-minute Session $160 • Letter Writing on your behalf $90/30 minutes or $160/50 minutes. • Missed Appointment Fee Full Session Fee of scheduled session. • Cancellation less than 24-hour Full Session Fee of scheduled session. • Telephone Consult with you or With a third party (MD, Psychiatrist, Other therapist, case worker, etc…) No charge for first 10 minutes $60/15 minutes after. • Outside of session reading reports Assessments or other documents You or a third party send me. No charge for 10 minutes, $60/15 minutes thereafter. • Returned Check Fee $35 or Bank Fee if higher. Payment: You agree to abide by its termspay the session fee in full at the end of each session as well as any other fees that are outstanding before another session may be scheduled. I authorize my insurance company accept a personal check, cash or Venmo only. Please have the exact amount as I will not be able to forward the Explanation of Benefits (EOB) and related payments to provide change. No credit cards are accepted. Checks are made out to: Xxxxxx X. XxxxXxxxxx, M.D. Patient Signature Date INTERNAL MEDICINE GROUP OF TAMPA BAY ID# ***UPDATED OFFICE POLICIES*** Effective January 1MS, 2014 As part of our ongoing efforts to make your experience with us a pleasant one, and to ensure your continued satisfaction with our services, we have adopted some additional office policiesLPC. Please read carefully, and initial the following updates. Feel free to speak with our staff should you have any questions or concerns about these policies. Blood work is required before all physical exams. If a patient misses a pre- physical blood work appointment, their physical exam will be canceled, and will need to be rescheduled. Payment for any required insurance co-pay, self-pay charge, and/or any outstanding balance on a patient’s account will be required at time of visit. A $25.00 non refundable no show fee will be applied to the patient’s account for an appointment missed without a 24 hour notice to cancel. This fee is not covered by insurance. It is the sole responsibility of the patient. As a consideration to other patients, patients who are 20 minutes or more late for their appointment will be rescheduled to another time. All prescription requests require a minimum 24 hour turnaround time for processing. Thank you for your cooperation. We look forward to your continued care with us. Patient’s Name: Patient’s Client Signature: Date: Witness SignaturePage 2 of 2-Fees and Financial Agreement Insurance: Date: _ INTERNAL MEDICINE GROUP OF TAMPA BAY ***INSURANCE COVERAGE NOTICE*** I, understand that the following may not be covered by my insurance; laboratory testing, including but not limited to Labcorp, Quest Diagnostics, ECG/EKG, vaccinations, and/or injection therapy. I understand I will be responsible for 100% of the billed cost for any of the above tests/procedures not covered by my insurance. I also understand that it is my responsibility as the patient, and the policy holder to contact my insurance company to inquire as to what services are covered. I also understand that any lab work done at INTERNAL MEDICINE GROUP OF TAMPA BAY invoice(s) I receive for lab fees are from the lab directly, therefore all billing issues need to be addressed with the lab directly. I as a patient of Internal Medicine Group of Tampa Bay understand that my physical exam must be scheduled a year and a day from my last physical in order for the exam to be covered by insurance. I also understand that it is my responsibility to confirm the date of my last physical exam before scheduling. If my appointment is scheduled before the one year and one day required by my insurance, I understand that I will be financially responsible for the appointment and all services provided. _____________________________________________________ _________________ Patient Signature Date Witness Signature Date 00000 Xxxxx Xxxxx Xxxx Xxxxx X Xxxxx, XX 00000 Phone: (000) 000-0000 Fax: (000) 000-0000 INTERNAL MEDICINE GROUP OF TAMPA BAY *PERMISSION TO RELEASE PROTECTED MEDICAL INFORMATION* The doctor and staff at INTERNAL MEDICINE GROUP OF TAMPA BAY cannot discuss your protected health information (PHI) with anyone other than yourself unless you authorize us to do so. Please list below the names(s) of the individual(s) you authorize our office to discuss your care with. Your PHI will be disclosed to the individual(s) listed below until you notify us otherwise in writing. This authorization will remain in effect for one year unless otherwise specified. I understand by signing this form I authorize the release of all medical records, which may include psychiatric information, genetic counseling (Acquired Immunodeficiency Syndrome), and/or may include the result of an HIV test. I understand that my (PHI) may be used or disclosed under this authorization, and may be subject to re-disclosure, thus my PHI may no longer be protected by law. By signing this authorization I expressly consent to the release of information as designated above. I understand I must notify INTERNAL MEDICNE GROUP OF TAMPA BAY, in writing, where the original authorization is retained, in order to discontinue this consent to release. I, give my permission for the following person (s) to receive my medical information. Name: Relationship: Signature Date INTERNAL MEDICNE GROUP OF TAMPA BAY I, authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to contact me by home phone, cell phone, fax, and/or email, and leave detailed messages regarding all test results, and/or reminders for future scheduled appointments. Patient Home Phone # Patient Cell Phone # Patient Private Fax # Patient email address If there are any changes to the contact information previously provided to INTERNAL MEDICINE GROUP OF TAMPA BAY I understand that it is my responsibility to provide timely updates to my contact information on file. If I wish to update any information, or revoke permission for messages to be left regarding test results, I must contact INTERNAL MEDICINE GROUP OF TAMPA BAY in writing during normal business hours. Please initial below to indicate your authorization Yes I authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to leave messages. No I do not authorize INTERNAL MEDICINE GROUP OF TAMPA BAY work with insurance companies. Insurance companies require a client be assigned a mental health disorder diagnosis in or to leave messagesbe reimbursed for counseling services. Signature Date Print Name INTERNAL MEDICINE GROUP OF TAMPA BAY PRIVACY NOTICE Effective January 1This mental health disorder designation becomes part of your permanent health record and can be accessed by current and future employers, 2014 A copy of INTERNAL MEDICINE GROUP OF TAMPA BAY'S Privacy Practices is available at xxx.xxxxxxxxxxx.xxx or at our office. Acknowledgment of receipt of Notice of Privacy Practices: I, the insurance industry and other such entities that deem it necessary to have received notice of Privacy Practices from INTERNAL MEDICINE GROUP OF TAMPA BAY which has been updated for the new Omnibus Rule and has an effective date of September 23, 2013. We encourage you to review it carefully. Our notice of Privacy Practices is subject to changeyour personal health record. If we change our Noticeyou want to assume the risk, I will provide you a receipt that you may submit for possible reimbursement as an out-of-pocket provider if that benefit is part of your plan. I do not call or correspond with your insurance company or provide additional paperwork other than a receipt. You are responsible for payment in full at the end of each scheduled session. Agreement: By signing below, you may obtain a copy at the front desk. The notice describes: • the ways the Privacy Rule allows our practice to use indicate that you have read, understand and disclose protected health information. How our practice will get your permission, or authorization, before using your health records for any other reason. • the practice's duties to protect health information privacy. • the patient's privacy rights, including the right to complain to HHS and agree to the covered entity if terms and conditions outlined in this Financial Agreement document (2 pages). Your signature also indicates that you believe your privacy rights have been violatedhad the opportunity to ask questions and/or discuss any concerns with me in the first, intake, session. • how to contact our practice for more information and to make a complaint. I understand that the Privacy Practices may be revised from time to time and that I have the right to receive an updated copy upon request.Client Name (Print):

Missed Appointments. We understand that unforeseen events happen that If I do not hear from you after a missed appointment and have reason for concern, I may prevent reach out to your identified emergency contact to ensure your well-being. If you do not show up for an appointment this will be considered a patient from making his/her appointment; however patients no-show and you will be charged the missed appointment fee of $50.00 Two no shows in a nonrow, may require us to dis- continue treatment. Late appointments: All sessions begin at the scheduled time and last 53 minutes. If you arrive late, we will meet until 53 minutes after your scheduled session time. Please note that multiple missed/cancelled appointments and late arrivals may require us to discontinue treatment. In this circumstance, I will discuss with you in person or by phone how we should proceed. At the end of each session we will make sure to have the following session scheduled. You should receive a 48 e-refundable $25.00 no-show fee after his/her second mail reminder and 24 hour text reminder about your scheduled appoint- ments. EAP”s and Medicaid do not allow charges for missed sessions or cancelled session. Therefore if you are using EAP or Medicaid you will be allowed ONE less than 24 hour cancellation or missed appointment. To avoid this feeIn Summary: A credit card will be kept on file. (I use Ivy Pay, kindly call 24 hours prior and cancel or reschedule any appointment(swhich is a HIPPA compliant secure site). As On the third less than 24 hour cancellation in a courtesyyear, patients your card will receive be charged $50.00. If you miss your appointment and do not call me before the appointment your card will be charged $50.00. Medicaid and EAP clients cannot be charged. If you are using Medicaid as a reminder phone call from our office the business day prior to his/her primary in- surance or an EAP, you are allowed one less than 24 hour cancellation and one missed appointment. I have read the Patient Financial Policy and agree to abide by its terms. I authorize my insurance company to forward the Explanation of Benefits (EOB) and related payments to Xxxxxx X. Xxxx, M.D. Patient Signature Date INTERNAL MEDICINE GROUP OF TAMPA BAY ID# ***UPDATED OFFICE POLICIES*** Effective January 1, 2014 As part of our ongoing efforts to make your experience with us a pleasant one, and to ensure your continued satisfaction with our services, we have adopted some additional office policies. Please read carefully, and initial the following updates. Feel free to speak with our staff should If you have any questions or concerns about these policiesare unclear, please do not hesitate to contact me. Blood work Please initial indicating you have read and understood the terms of the attendance policy. Communication: The most secure form of communication is required before all physical examsby phone or voicemail. I have a secure voice mail, 000 000-0000 and a secure e-mailI; xxxxxxx@xxxxxxxxxxxxxxxxxxx.xxx. if you need to reach me outside of your session time, I encourage you to call my office number 000 000-0000. If a patient misses a pre- physical blood work appointment, their physical exam will be canceled, you are distressed and will feel the need to be rescheduled. Payment for any required insurance cocall me outside of our regular meeting time, please know that I am only available via phone from 9-pay, self-pay charge, and/or any outstanding balance on a patient’s account will be required at time of visit. A $25.00 non refundable no show fee will be applied to the patient’s account for an appointment missed without a 24 hour notice to cancel. This fee is not covered by insurance. It is the sole responsibility of the patient. As a consideration to other patients, patients who are 20 minutes or more late for their appointment will be rescheduled to another time. All prescription requests require a minimum 24 hour turnaround time for processing. Thank you for your cooperation. We look forward to your continued care with us. Patient’s Name: Patient’s Signature: Date: Witness Signature: Date: _ INTERNAL MEDICINE GROUP OF TAMPA BAY ***INSURANCE COVERAGE NOTICE*** I, understand that the following may not be covered by my insurance; laboratory testing, including but not limited to Labcorp, Quest Diagnostics, ECG/EKG, vaccinations, and/or injection therapy6. I understand will return your call within 24 hours. E-mail and phone are usually for scheduling, outside homework or business related is- sues and not intended to replace a therapy sessions. Social Media I will maintain multiple social media accounts for my practice. These accounts serve to promote my services and offer encouragement and resources. They are not a substitute for treatment by a licensed mental health professional and nothing shared should be responsible for 100% of the billed cost for any of the above tests/procedures interpreted as a personal message. I do not covered by my insuranceinteract with clients via social media. I also understand do not expect you to follow any of my ac- counts based on our work together. If you choose to follow one of my accounts and do reach out to me via that it is my responsibility as the patientmethod, and the policy holder to contact my insurance company to inquire as to what services are coveredwe will discuss that further in our next session. I also understand that any lab work done at INTERNAL MEDICINE GROUP OF TAMPA BAY invoice(s) I receive for lab fees are from the lab directly, therefore all billing issues need to be addressed with the lab directly. I as a patient of Internal Medicine Group of Tampa Bay understand that my physical exam must be scheduled a year and a day may remove your com- munication/comment/message from my last physical in order for the exam to be covered by insurance. account if I also understand that feel it is my responsibility to confirm the date of my last physical exam before scheduling. If my appointment is scheduled before the one year and one day required by my insurance, I understand that I will be financially responsible for the appointment and all services provided. _____________________________________________________ _________________ Patient Signature Date Witness Signature Date 00000 Xxxxx Xxxxx Xxxx Xxxxx X Xxxxx, XX 00000 Phone: (000) 000-0000 Fax: (000) 000-0000 INTERNAL MEDICINE GROUP OF TAMPA BAY *PERMISSION TO RELEASE PROTECTED MEDICAL INFORMATION* The doctor and staff at INTERNAL MEDICINE GROUP OF TAMPA BAY cannot discuss violates your protected health information (PHI) with anyone other than yourself unless you authorize us to do so. Please list below the names(s) of the individual(s) you authorize our office to discuss your care with. Your PHI will be disclosed to the individual(s) listed below until you notify us otherwise in writing. This authorization will remain in effect for one year unless otherwise specified. I understand by signing this form I authorize the release of all medical records, which may include psychiatric information, genetic counseling (Acquired Immunodeficiency Syndrome), and/or may include the result of an HIV test. I understand that my (PHI) may be used or disclosed under this authorization, and may be subject to re-disclosure, thus my PHI may no longer be protected by law. By signing this authorization I expressly consent to the release of information as designated above. I understand I must notify INTERNAL MEDICNE GROUP OF TAMPA BAY, in writing, where the original authorization is retained, in order to discontinue this consent to release. I, give my permission for the following person (s) to receive my medical information. Name: Relationship: Signature Date INTERNAL MEDICNE GROUP OF TAMPA BAY I, authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to contact me by home phone, cell phone, fax, and/or email, and leave detailed messages regarding all test results, and/or reminders for future scheduled appointments. Patient Home Phone # Patient Cell Phone # Patient Private Fax # Patient email address If there are any changes to the contact information previously provided to INTERNAL MEDICINE GROUP OF TAMPA BAY I understand that it is my responsibility to provide timely updates to my contact information on file. If I wish to update any information, or revoke permission for messages to be left regarding test results, I must contact INTERNAL MEDICINE GROUP OF TAMPA BAY in writing during normal business hoursconfidentiality. Please initial below to indicate your authorization Yes indicating you have read and understood the terms of the communi- cations police. Payment: I authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to leave messages. No I do not authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to leave messages. Signature Date Print Name INTERNAL MEDICINE GROUP OF TAMPA BAY PRIVACY NOTICE Effective January 1, 2014 A copy of INTERNAL MEDICINE GROUP OF TAMPA BAY'S Privacy Practices is available at xxx.xxxxxxxxxxx.xxx or at our office. Acknowledgment of receipt of Notice of Privacy Practices: I, have received notice of Privacy Practices from INTERNAL MEDICINE GROUP OF TAMPA BAY which has been updated for the new Omnibus Rule and has an effective date of September 23, 2013. We encourage you to review it carefully. Our notice of Privacy Practices is subject to change. If we change our Notice, you may obtain a copy require payment at the front deskbeginning of each session. The notice describes: • the ways the Privacy Rule allows our practice to use and disclose protected health information. How our practice will get your permissionYou may pay via cash, check or authorization, before using your health records for any other reason. • the practice's duties to protect health information privacy. • the patient's privacy rights, including the right to complain to HHS and to the covered entity if you believe your privacy rights have been violated. • how to contact our practice for more information and to make a complaint. I understand that the Privacy Practices may be revised from time to time and that I have the right to receive an updated copy upon requestcredit card.

Missed Appointments. We understand In the event that unforeseen events happen that may prevent you are unable to keep a patient from making his/her scheduled appointment; however patients , it is your responsibility to notify me with no less than 24-hour notice or you will be charged liable for the full session fee of $150. If your appointment is scheduled for a non-refundable Monday, you must cancel before Sunday or the $25.00 no-show 150 fee after his/her second missed appointment. To avoid this fee, kindly call 24 hours prior and cancel or reschedule any appointment(s). As a courtesy, patients will receive a reminder phone call from our office the business day prior to his/her appointmentapplies. I have read collect payment and schedule your next appointment at the Patient Financial Policy end of our 50-minute session. My fees for sessions and services are: • 50-minute Session $150 • Letter Writing on your behalf $90/30 minutes or $150/50 minutes. • Missed Appointment Fee Full Session Fee of scheduled session. • Cancellation less than 24-hour Full Session Fee of scheduled session. • Telephone Consult with you or With a third party (MD, Psychiatrist, Other therapist, case worker, etc…) No charge for first 10 minutes $60/15 minutes after. • Outside of session reading reports Assessments or other documents You or a third party send me. No charge for 10 minutes, $60/15 minutes thereafter. • Returned Check Fee $35 or Bank Fee if higher. Payment: You agree to abide by its termspay the session fee in full at the end of each session as well as any other fees that are outstanding before another session may be scheduled. I authorize my insurance company accept a personal check, cash or Venmo only. Please have the exact amount as I will not be able to forward the Explanation of Benefits (EOB) and related payments to provide change. No credit cards are accepted. Checks are made out to: Xxxxxx X. XxxxXxxxxx, M.D. Patient Signature Date INTERNAL MEDICINE GROUP OF TAMPA BAY ID# ***UPDATED OFFICE POLICIES*** Effective January 1MS, 2014 As part of our ongoing efforts to make your experience with us a pleasant one, and to ensure your continued satisfaction with our services, we have adopted some additional office policiesLPC. Please read carefully, and initial the following updates. Feel free to speak with our staff should you have any questions or concerns about these policies. Blood work is required before all physical exams. If a patient misses a pre- physical blood work appointment, their physical exam will be canceled, and will need to be rescheduled. Payment for any required insurance co-pay, self-pay charge, and/or any outstanding balance on a patient’s account will be required at time of visit. A $25.00 non refundable no show fee will be applied to the patient’s account for an appointment missed without a 24 hour notice to cancel. This fee is not covered by insurance. It is the sole responsibility of the patient. As a consideration to other patients, patients who are 20 minutes or more late for their appointment will be rescheduled to another time. All prescription requests require a minimum 24 hour turnaround time for processing. Thank you for your cooperation. We look forward to your continued care with us. Patient’s Name: Patient’s Client Signature: Date: Witness SignaturePage 2 of 2-Fees and Financial Agreement Insurance: Date: _ INTERNAL MEDICINE GROUP OF TAMPA BAY ***INSURANCE COVERAGE NOTICE*** I, understand that the following may not be covered by my insurance; laboratory testing, including but not limited to Labcorp, Quest Diagnostics, ECG/EKG, vaccinations, and/or injection therapy. I understand I will be responsible for 100% of the billed cost for any of the above tests/procedures not covered by my insurance. I also understand that it is my responsibility as the patient, and the policy holder to contact my insurance company to inquire as to what services are covered. I also understand that any lab work done at INTERNAL MEDICINE GROUP OF TAMPA BAY invoice(s) I receive for lab fees are from the lab directly, therefore all billing issues need to be addressed with the lab directly. I as a patient of Internal Medicine Group of Tampa Bay understand that my physical exam must be scheduled a year and a day from my last physical in order for the exam to be covered by insurance. I also understand that it is my responsibility to confirm the date of my last physical exam before scheduling. If my appointment is scheduled before the one year and one day required by my insurance, I understand that I will be financially responsible for the appointment and all services provided. _____________________________________________________ _________________ Patient Signature Date Witness Signature Date 00000 Xxxxx Xxxxx Xxxx Xxxxx X Xxxxx, XX 00000 Phone: (000) 000-0000 Fax: (000) 000-0000 INTERNAL MEDICINE GROUP OF TAMPA BAY *PERMISSION TO RELEASE PROTECTED MEDICAL INFORMATION* The doctor and staff at INTERNAL MEDICINE GROUP OF TAMPA BAY cannot discuss your protected health information (PHI) with anyone other than yourself unless you authorize us to do so. Please list below the names(s) of the individual(s) you authorize our office to discuss your care with. Your PHI will be disclosed to the individual(s) listed below until you notify us otherwise in writing. This authorization will remain in effect for one year unless otherwise specified. I understand by signing this form I authorize the release of all medical records, which may include psychiatric information, genetic counseling (Acquired Immunodeficiency Syndrome), and/or may include the result of an HIV test. I understand that my (PHI) may be used or disclosed under this authorization, and may be subject to re-disclosure, thus my PHI may no longer be protected by law. By signing this authorization I expressly consent to the release of information as designated above. I understand I must notify INTERNAL MEDICNE GROUP OF TAMPA BAY, in writing, where the original authorization is retained, in order to discontinue this consent to release. I, give my permission for the following person (s) to receive my medical information. Name: Relationship: Signature Date INTERNAL MEDICNE GROUP OF TAMPA BAY I, authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to contact me by home phone, cell phone, fax, and/or email, and leave detailed messages regarding all test results, and/or reminders for future scheduled appointments. Patient Home Phone # Patient Cell Phone # Patient Private Fax # Patient email address If there are any changes to the contact information previously provided to INTERNAL MEDICINE GROUP OF TAMPA BAY I understand that it is my responsibility to provide timely updates to my contact information on file. If I wish to update any information, or revoke permission for messages to be left regarding test results, I must contact INTERNAL MEDICINE GROUP OF TAMPA BAY in writing during normal business hours. Please initial below to indicate your authorization Yes I authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to leave messages. No I do not authorize INTERNAL MEDICINE GROUP OF TAMPA BAY work with insurance companies, except BCBS of NC. Insurance companies require a client be assigned a mental health disorder diagnosis in or to leave messagesbe reimbursed for counseling services. Signature Date Print Name INTERNAL MEDICINE GROUP OF TAMPA BAY PRIVACY NOTICE Effective January 1This mental health disorder designation becomes part of your permanent health record and can be accessed by current and future employers, 2014 A copy of INTERNAL MEDICINE GROUP OF TAMPA BAY'S Privacy Practices is available at xxx.xxxxxxxxxxx.xxx or at our office. Acknowledgment of receipt of Notice of Privacy Practices: I, the insurance industry and other such entities that deem it necessary to have received notice of Privacy Practices from INTERNAL MEDICINE GROUP OF TAMPA BAY which has been updated for the new Omnibus Rule and has an effective date of September 23, 2013. We encourage you to review it carefully. Our notice of Privacy Practices is subject to changeyour personal health record. If we change our Noticeyou want to assume the risk, I will provide you a receipt that you may obtain submit for possible reimbursement as an out-of-pocket provider if that benefit is part of your plan. I do not call or correspond with your insurance company or provide additional paperwork other than a copy receipt. You are responsible for payment in full at the front desk. The notice describes: • the ways the Privacy Rule allows our practice to use and disclose protected health information. How our practice will get your permission, or authorization, before using your health records for any other reason. • the practice's duties to protect health information privacy. • the patient's privacy rights, including the right to complain to HHS and to the covered entity if you believe your privacy rights have been violated. • how to contact our practice for more information and to make a complaint. I understand that the Privacy Practices may be revised from time to time and that I have the right to receive an updated copy upon requestend of each scheduled session.