It is my responsibility to ensure provider network status with my insurance company. I hereby authorize the designated physician to release any information acquired, during my treatment to my insurance company for completion of claims in consideration of the medical services to be rendered.

I understand that I am responsible for all charges not paid by insurance. I am aware that services rendered are subject to my copayment, deductible, co-insurance, and out of pocket maximums as deemed by my insurance company. I agree to pay Triad Internal Medicines the regular charges for said services. Billing cycles can take up to 6 months depending on the processing of my insurance claim. I agree to always keep a current insurance on file with Triad Internal Medicine. I authorize being billed as self-pay if my insurance states I am inactive. Triad Internal Medicine will not rebill my insurance. For all high deductible insurance plans, an upfront deposit of $100 is collected upon check-in. Once insurance clears my claim, this will be credited towards my balance. I understand that I will be billed the remaining portion. If overpayment has occurred, Triad Internal Medicine will refund me. I also have the option of keeping a credit card or HSA card on file for balances to be charged to my card once insurance deems my financial responsibility.

All self-pay patient are required to pay $150 upon check-in and remaining balances will be billed after the visit. Any returned and unprocessed check will result in a fee of $35 that will be charged to the patient. Appointments that are missed or cancelled within 24 hours of appointment time are subject to a $75.00 fee billed to me.

Form charges- Requests for completion of several types of forms and correspondence will incur fees. Examples include disability forms, FMLA forms, letters for insurance companies or third-party payors. Some forms will require a visit with your provider.

Past due balances over 90 days will be sent to a collection agency. A $35 collection agency fee will be charged to your account. Once your account is transferred to a collection agency, you are discharged as a patient of Triad Internal Medicine. We will make every effort to work with you and offer a payment plan dependent on the balance due. Please contact our billing office for details.

This authorization outlines who, medical information about you may be shared. Please read it carefully. The privacy of your medical information is important to us. Our Notice of Privacy Practices outlines how we may use or disclose your medical information on a regular basis. This authorization is for situations not included in the Notice This Authorization allows the individual(s) listed to have access to all or part of your information as specified below. This Authorization will remain in effect for a period of five years from the date signed.

Who may receive your health information?

Revocation

This Authorization will remain in effect for a period of five years from the date signed. However, you have the right to revoke this Authorization at any time as long as the revocation is made in writing and is received and acknowledged by Triad Internal Medicine. Such revocation will restrict disclosures of your medical information but cannot affect past disclosures or disclosures underway at the time of receipt.

Consent to Treatment

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that

(1) You intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and

(2) You consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing.

You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice.

I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

Please review to ensure the details are correct before completion.