GENERAL CONSENT AND SERVICE TERMS

General Consent for Treatment: I agree to allow Pulmonary Practice Associates (Pulmonary Practice Associates) to provide all health care services to me that are routine or otherwise deemed necessary. I understand I have the right to refuse consent to any proposed procedure or treatment at any time prior to receiving it. I understand that any treatment involving material risks will be explained to me and that I will have the opportunity to ask questions about the associated risks, alternatives and prognosis before allowing the treatment to be performed. I agree that no guarantees have been given to me as to the outcome of any treatment. I agree my picture can be taken to identify me.

General Sharing Health Information: I agree to Pulmonary Practice Associates using and sharing all my health information, including but not limited to Highly Confidential Information (see definition below), for payment, my continued treatment, and healthcare operations. This includes sharing my information with the following:

• All physicians and other medical service providers associated with my treatment, as well as other physicians who are participating in integrated physician plan networks or Health Information Exchanges.
• Business partners of Pulmonary Practice Associates, its affiliates, and Physicians, who provide administrative, operational, financial, legal and technical support services.
• All insurance Payer(s) and healthcare plans responsible for paying or determining if I am eligible for payment for my treatment.

Substance, Drug, and Alcohol Abuse Authorization: I authorize and have initialed below for Pulmonary Practice Associates to release, should any exist, all my substance abuse and drug and alcohol abuse health information to any affiliate for my treatment, payment for my treatment, and the health care operations of Pulmonary Practice Associates. I understand this authorization may be cancelled at any time, unless Pulmonary Practice Associates have already acted and relied on it. If not previously revoked, I understand this authorization is effective until I am deceased.

Insurance Assignment and Payment: I permanently assign my third-party payer benefits payable directly to Pulmonary Practice Associates. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any services rendered.
I authorize Pulmonary Practice Associates to file an appeal on my behalf for any denial of payment and/or adverse benefit determination related to services and care provided. If my health insurance or third-party payer will not direct payment to Pulmonary Practice Associates, I agree to forward Pulmonary Practice Associates all health insurance payments which I receive for the services rendered by Pulmonary Practice Associates. Unless otherwise designated by the payer, I understand Pulmonary Practice Associates posts all payments received to the oldest balances first, except for copays, drugs and supplies. I give permission to apply and credit balances to offset amounts due to Pulmonary Practice Associates where I have received services for current accounts or accounts I have not paid yet.

Note: This document contains protected health information (PHI) and is subject to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Unauthorized use or disclosure of PHI is strictly prohibited. If you are not the intended recipient or have received this document in error, please notify the sender immediately. Please be aware that any unauthorized review, disclosure, copying, distribution, or taking any action in reliance on the contents of this document is prohibited.