Patient Responsibility Form
- INDIVIDUAL'S FINANCIAL RESPONSIBILITY
- I understand that I am financially responsible for my health insurance
deductible, coinsurance or non-covered service.
- Co-payments are due at time of service.
- If my plan requires a referral, I must obtain it prior to my visit
- In the event that my health plan determines a service or hearing device not
be a covered benefit, I will be responsible for the complete charge and
agree to pay the costs of all services provided.
- If I am uninsured, I agree to pay for the medical services rendered to me at
Ultimately, it is the patient's responsibility to verify their insurance benefit.
To save time, please be sure to call your insurance company before your
INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
I hereby authorize and direct payment of my medical benefits to Diablo Hearing
Services, Inc. on my behalf for any services furnished to me by the providers.
- AUTHORIZATION TO RELEASE RECORDS
I hereby authorize Diablo Hearing Services, Inc. to release to my insurer,
governmental agencies, or any other entity financially responsible for my
medical care, all information, including diagnosis and the records of any
treatment or examination rendered to me needed to substantiate payment for such
medical services as well as information required for precertification,
authorization or referral to other medical provider.
- MEDICARE REQUEST FOR PAYMENT
I request payment of authorized Medicare benefits to me or on my behalf for any
services furnished me by or in Diablo Hearing Services, Inc. I authorize any
holder of medical or other information about me to release to Medicare and its
agents any information needed to determine these benefits or benefits for
[Signature and date will be requested during office visit]
This document acknowledges that you have received a copy of the Notice of Privacy
Practices. This document is not a contract, authorization, release, or consent form. This document will
remain in your records.
Acknowledge that I have received a copy of the Notice of Privacy Practices.
If the patient is a minor, a parent or legal guardian must sign.
If the patient is NOT a minor, but under the care of a friend, relative, or caregiver.
Notice of Policy Practices
All information that is obtained from you by this office is protected and kept confidential. Every
reasonable measure to prevent unauthorized disclosure of your protected health information is
Uses and Disclosures
- Your protected health information is accessed and used for healthcare related purposes only.
- Your protected health information is never sold, rented, transferred, exchanged, and/or used for
non-healthcare related purposes including marketing activities without your written authorization.
- Your protected health information is disclosed to third-party entities without your written
authorization for the purpose of treatment, to obtain payment for treatment and for healthcare
Your protected health information can be disclosed without your written authorization in certain limited
- Medical emergencies
- In situations required by law
- Individuals involved in your care
- When requested by public health agency
- When requested by a law enforcement agency
For any purpose other than treatment, obtaining payment, healthcare operations, or certain
circumstances, we will ask for your written authorization before using or disclosing your protected
healthcare information. If you choose to sign an authorization to disclose protected health
information, you can revoke that authorization in writing at any time.
- You have the right to request in writing to inspect and/or receive a copy of your health
- You have the right to request an alternate means or location to receive communications regarding
your health information.
- You have the right to request in writing to amend, correct, or delete any recorded health
information within our possession.
- You have the right to request in writing to restrict some uses and disclosures of your health
- You have the right to request in writing an accounting of certain disclosures of your health
information that were made by this office.
Changes to this Notice: We reserve the right to change privacy practices and the conditions of
this notice at any time and without prior notice. In the event of changes, and updated notice will be
posted and a copy will be made available to you.