Consent Agreement *
IN ORDER TO MAINTAIN CONTINUITY OF CARE, I GIVE PERMISSION TO SOUTHERN PRIMARY CARE TO
RELEASE MY MEDICAL RECORDS TO ANY SPECIALISTS, HOSPITALS OR MEDICAL FACILITIES
ASSOCIATED WITH MY CARE PLAN. I UNDERSTAND THAT SOUTHERN PRIMARY CARE ABIDES BY HIPAA
REGULATIONS AND THAT ONLY THE RECORDS PERTINENT TO THE VISIT WILL BE RELEASED. I
AUTHORIZE THE RELEASE OF MEDICAL INFORMATION NECESSARY TO PROCESS INSURANCE CLAIMS.
IT IS THE POLICY OF OUR PRACTICE THAT ALL PHYSICIANS AND STAFF MEMBERS PRESERVE THE
INTEGRITY AND THE CONFIDENTIALITY OF PROTECTED HEALTH INFORMATION (PHI) PERTAINING TO
OUR PATIENTS. THE PURPOSE OF THIS POLICY IS TO ENSURE THAT OUR ENTIRE PRACTICE HAVE
THE NECESSARY MEDICAL AND (PHI) TO PROVIDE OUR PATIENTS THE HIGHEST QUALITY MEDICAL
CARE POSSIBLE. PATIENTS SHOULD NOT BE AFRAID TO PROVIDE INFORMATION TO OUR PRACTICE,
PHYSICIANS, STAFF MEMBERS FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTHCARE
PROCEDURES. OUR HIPAA POLICY IN ITS ENTIREY CAN BE OBTAINED THROUGH OUR OFFICE AT ANY
TIME. LET US KNOW IF YOU WOULD LIKE TO RECEIVE A COPY PRIOR TO SIGNING THIS CONSENT. I
HEREBY ACKNOWLEDGE THAT SOUTHERN PRIMARY CARE WILL SHARE MY MEDICAL INFORMATION, AS
PERMITTED UNDER FEDERAL LAW (HIPAA) AND GEORGIA STATE LAW, WITH MY HEALTHCARE
PROVIDERS THROUGH A HEALTH INFORMATION EXCHANGE. BY SIGNING THIS FORM, I AUTHORIZE
THAT I FULLY UNDERSTAND THE RULES AND REGULATIONS PERTAINING HIPAA POLICY.
BY SIGNING THIS FORM, I AUTHORIZE THE REVIEW OF MY PRESCRIPTION HISTORY FOR REASONS OF
EVALUATION AND TREATMENTS.
RELEASE AUTHORIZATION OF MEDICAL INFORMATION
ALSO, IT IS OUR EXPERIENCE THAT SOME PATIENTS MAY OR MAY NOT WISH FOR OUR STAFF TO
DISCUSS MEDICAL CONDITIONS/INFORMATION WITH FAMILY MEMBERS. PLEASE SPECIFY ANY FAMILY
MEMBERS WHO MAY OBTAIN OR CALL AND DISCUSS YOUR MEDICAL INFORMATION.
DURING THE COURSE OF MY CARE AND TREATMENT, I UNDERSTAND THAT VARIOUS TYPES OF TESTS,
DIAGNOSTIC OR TREATMENT PROCEDURES MAY BE NECESSARY. THESE PROCEDURES MAY BE PERFORMED
BY PHYSICIANS, NURSES, TECHNICIANS, PHYSICIAN ASSISTANTS OR OTHER HEALTHCARE
PROFESSIONALS (HEALTHCARE PROFESSIONALS) AT SOUTHERN PRIMARY CARE.I ALSO UNDERSTAND
THAT VARIOUS HEALTHCARE PROFESSIONALS MAY HAVE DIFFERING OPINIONS AS TO WHAT
CONSTITUES MATERIAL RISKS AND ALTERNATIVE PROCEDURES. THE PRACTICE OF MEDICAINE IS NOT
AN EXACT SCIENCE AND THAT NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO ME CONCERNING
THE OUTCOME AND/OR RESULT OF ANY PROCEDURES;THE HEALTHCARE PROFESSIONAL PARTICIPATING
IN MY CARE WILL RELAY ON MY DOCUMENTED MEDICAL HISTORY, AS WELL AS OTHER INFORMATION
OBTAINED FROM ME, FAMILY OR OTHERS HAVING KNOWLEDGE ABOUT ME, IN DERTERMINING WHETHER
TO PERFORM OR RECOMMEND THE PROCEDURES THEREFORE, I AGREE TO PROVIDE ACCURATE AND
COMPLETE INFORMTION ABOUT MY MEDICAL HISTORY AND CONDITIONS.BY SIGNING THIS FORM, I
CONSENT TO HEALTHCARE PROFESSIONALS PERFORMING PROCEDURES AS THEY MAY DEEM REASONABLY
NECESSARY OR DESIRABLE IN THE EXERCISE OF THEIR PROFESSIONAL JUDGMENT, INCLUDING THOSE
PROCEDURES THAT MAY BE UNFORESEEN OR NOT KNOWN TO BE NEEDED AT THE TIME THIS CONSENT
IS OBTAINED; AND I ACKNOWLEDGE THAT I HAVE BEEN INFORMED IN GENERAL TERMS OF THE
NATURE AND PURPOSE OF THE PROCEDURES, THE MATERIAL RISKS OF PROCEDURES, AND PRACTICAL
ALTERNATIVES OF THE PROCEDURES. I ALSO UNDERSTAND THAT I CAN AT ANY TIME ASK MY
PHYSICIAN TO PROVIDE ME WITH ADDITIONAL INFORMATION.
REFERRAL/PRIOR AUTHORIZATION/PRIOR CERTIFICATION
If your plan requires a referral, it is your responsibility to obtain this
prior to being seen by a specialist. If we are required to obtain the referral
or prior authorization/certification for you, please notify our office 5
days prior to the specialist's visit or procedure so that we have ample time
to acquire this information from your insurance company. Per office policy,
we do not back date referrals or prior authorization/certification.
REFILL REQUEST and NURSE CALLS
Please allow 3 business days for your refill request to be filled. Although
we will try to return patient telephone request within 48 hours, we ask that
you kindly give our staff 72 hours to return any requests. Please have the
pharmacy fax the request to us at 1 (888) 291 - 5615. Most medication refills
may require a follow-up visit with the physician. Antibiotics and pain
medication will not be called in. An appointment with the physician will be
required to replace lost or misplace prescriptions.
OFFICE POLICY ON MANAGED CARE INSURERS
We are pleased to meet the needs of our patients by enrolling with various
managed care insurance programs. While we are able to provide you with this
service, it is extremely difficult to keep track of all the individual
insurance requirements of each plan. Even with the same insurance company,
plans often may differ. Providing quality medical care for our patients is
our primary concern, and we are more than willing to provide that care based
on your insurance contract guidelines. We request at each visit that you
advise us of your guidelines. Unfortunately, if you do not inform us of any
special requirements in your contract and subsequently provide: Services, or
order services such as label work or procedures that are not covered, the
office will have no choice but to bill you directly for all said charges. All
fees submitted and denied by your insurance carrier will become your
responsibility. With your cooperation, you should be able to receive all
benefits offered by your insurance plan, and we will be able to concentrate on
caring for your medical needs.
Welcome to our office. We are pleased to have you as a patient. We are
committed to meeting your health care needs. It is our goal to provide you
with the best possible health care and to keep your insurance or other
financial arrangements as simple as possible. In order to accomplish this in a
cost-effective manner, we ask that you adhere to the following guidelines:
1. You are ultimately responsible for payment of services you rendered from our
office. Please contact your insurance company to confirm coverage and benefits.
We can never guarantee coverage for any service provided by our office. You are
responsible for any services that the insurance does not cover, such as but not
limited to well visits, procedures, injections and immunizations, balance left
after all insurance payments and contracted adjustments.
2. It is your responsibility to provide us with your current address,
telephone number, and insurance information at each visit. If you do not
have proof of current insurance at your visit, you will be considered a selfpay patient for that visit and payment in full will be due at the time of
3. It is your responsibility to contact your insurance carrier to confirm
that our physicians participate in your plan and that we are your primary
care provider. If your insurance is a managed care plan, our Doctor must be
listed as the PCP. If our Doctor is not listed as the PCP, your visit will be
considered a self-pay patient for the visit and payment in full will be due at
the time of service.
4. All co-payments and deductibles are collected at the time of service.
5. RETURNED PAYMENT FOR NON-SUFFICIENT FUNDS WILL BE CHARGED $35.00.
6. COLLECTION AGENCY ADMINISTRATIVE CHARGE WILL BE CHARGED $25.00+.
7. COMPLETION OF ALL FORMS (NOT LIMITED TO) WILL BE CHARGED $25.00+.
8. NO SHOWS WILL BE CHARGED $25.00+ AND WE NEED ATLEAST 24HR CANCELLATION
WITH YOU, OUR PATIENT, WE LOOK FORWARD TO A LASTING AND HEALTHY RELATIONSHIP
AND WE THANK YOU FOR YOUR UNDERSTANDINH AND COOPERATION.
PLEASE NOTE: YOU MUST BE FAMILIAR WITH YOUR INSURANCE BENEFITS. YOU ARE
RESPONSIBLE FOR ANY BALANCE ON YOUR ACCOUNT AFTER 90 DAYS OF SUBMISSION OF
CLAIM TO INSURANCE COMPANY, WHETHER YOUR INSURANCE HAS PAID OR NOT.
PLEASE UNDERSTAND: WE FILE INSURANCE CLAIM AS A COURTESY TO OUR PATIENTS.
YOU HAVE A CONTRACT WITH YOUR INSURANCE COMPANY OF CHOICE. WE ARE NOT
RESPOINSIBLE FOR HOW YOUR INSURANCE COMPANY HANDLES ITS CLAIMS OR FOR THE
BENEFITS THEY PAY. WE DO NOT GURANTEE WHAT YOUR INSURANCE COMPANY WILL OR
WILL NOT DO WITH EACH CLAIM. THIS IS PERFORMED AS A COURTESY TO YOU.