GENERAL INFORMATION/ INFORMACION GENERAL
Pharmacia preferida:
Parent or Legal Guardian: I hereby authorize Women's Care of Mid Cities and/ or agents to use my general information (address, phone (text
messages), and email) to contact me to facilitate anything related to my medical care.
Authorization Form
Medicare Assignment of benefits to Statement to Permit of Heath and/or Medical insurance benefits To Women's Care of Mid Cities
I certify that the information given by me in applying for payment under title XVLlll of the Social Security Act is correct. I authorize any holder
of medical or other information about me to the centers for Medicare and Medicaid Services or its intermediaries or carriers any information
needed or for this or a related Medical claim. I request that payment of authorized benefits be made on my behalf.I assign the benefits
payable for physician and / or mid level (Nurse Practitioner or Physician Assistant) provider services to the provider or organization furnishing
the services or authorized such provider or organization
Financial Responsiblity
I understand that regardless of my assigned insurance benefits, I am responsible for the total charges for all services rendered and I agree to
honor the current Clinic payment policy. I understand that, in the unable to pay in full at the time service is rendered; Women's Care of Mid
Cities may inquiry of my credit history to evaluate my credit worthiness. I further understand that unpaid patient accounts may accrue
interest (1.5%)per month/ 18% per year) and I agree to pay any such interest charges in addition to any amount unpaid by any insurance
coverage. I further understand that should this account become delinquent and it becomes necessary for the account to be referred to as
attorney or collection agency for collection suit, I agree to pay all reasonable attorney fees and/ or collection expense.
Insurance Assignment
In consideration of services rendered or to be rendered, I hereby irrevocably assign and transfer to Women's Care of Mid Cities, Mesquite,
Texas any benefits under hospitalization, sickness liability, auto or accident insurance, and any other coverage for the payment of such
services rendered. I agree to cooperate, aid and assist the clinic in procuring all possible insurance benefits, including initiation and
fulfillment of all policy provisions such insurance companies may require for payment. I understand it is my responsibility to the provider for
charges not paid pursuant to this assignment.
Authorization For Care
I hereby authorize the staff of Women's Care of Mid Cities to administer such care/ treatment as it is necessary based on the clinical providers
assessment and diagnosis. I understand that such care may include medical and surgical treatment, and laboratory, and radiologic test. I
certify that no guarantee of assurance has been made to the results that may be obtained
Authorization For Release Of Information
I hereby authorize staff of Women's Care of Mid Cities to disclose necessary information from my medical record to the following parties
when requested for the purpose as stated herein: to any health care provider for the purpose of providing continuing professional care and
to any insurance company or third party payer (or their agent/s) for the purpose of obtaining payment to employees, offices and attending
clinical providers are released from legal responsibility or liability for the above information to the extent indicated and authorized herein. I
understand this released specifically includes any and all blood and related tests including test results reflecting presence of HIV, HBV and
other diseases, all of which I specifically authorize to be so released.
Authorization Form
Advanced practice nurses Consent for Medical Treatment
Women's Care of Mid Cities has an advanced practice nurse to assist in the delivery of primary health
care. Women's Care of Mid Cities is a family medical clinic that is owned and operated by Vishnu Maya
Upadhyay, a certified family and women’s health nurse practitioner.
A nurse practitioner is a registered nurse (RN), also known as
nurse practitioners (ANP) has a
Masters Degree in Nursing and a board certification in their specialty. They have education and training
in specialty areas such as family practice, women’s health or pediatrics. Family Nurse Practitioners have
acquired the necessary knowledge and expertise, skills and training in the care of people of all ages. I
have read this document and hereby confine the services of a nurse practitioner for my health care
needs.
Patient Consent Form
In April of 2003, new federal requirements regarding privacy of information for health care patients took effect. HIPAA, the Health Insurance Portability and Accountability Act requires that all medical providers, insurance companies, and others, put in place controls to ensure the your personal medical information is safe.
Women's Care of Mid Cities requires that each patient sign this consent form which allows us to share protected
health information with other physician offices, your hospital, and insurance company.
By signing this form, consent to our use and disclosure of protected health information about your treatment,
payment, and health care operation. You have the right to revoke this consent in writing, except where we have already made
disclosures in reliance on your prior consent.
Our Notice of Privacy Practices provides information about how we may use and disclose protected health
information about you. You have the right to review our notice before signing this consent.
Authorization to Release Information to Family Members
Many of our patients allow family members such as their spouse, parents, or other to call and request the results of tests and
procedures. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to
have your test results released to a family member you must sign this form. Signing this form will only give consent to release laboratory and
radiology results to family members indicated below. This consent will not allow Women's Care of Mid Cities Associates to release any other
information to these family members.
You have the right to revoke this consent in writing, except where we have already made disclosures in reliance to
your prior consent.
Authorization to Leave Messages with Household Members/ Answering Machine
From time to time it is necessary for representatives of Women's Care of Mid Cities to leave messages for patients. The
purposes of these messages is to remind patients that they have an appointment, to notify the patient that medical staff
would like to discuss lab or procedure results, or to ask a patient to call CMC regarding an issue or concern. The purpose of
this consent is to leave massages with members of your household or on your answering machine. You have the right to
revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.
Consent and acknowledgement of Receipt of Privacy Notice
I understand that as part of provision of healthcare service, Women's Care of Mid Cities, create and
maintain health record and other information describing among other things, my health history
symptoms, diagnosis, treatment, examination, and test results, prescription drug history, and any plans
for future care or treatment.
I have been provided with a notice of privacy practice that provides a more description of the use and
disclosures of certain health information. I understand that I have the right to review the notice prior to
signing this consent. I understand that the organization reserves the right to change their notice and
practices and prior to implementation will mail a copy of revised notice to the address I have provided. I
understand that I have the right to request restriction as to how my information may be used or
disclosed to carry out treatment, payment or healthcare operation (Quality assessment and
improvement activities, underwriting, premium rating, conducting or arranging for medical review,
legal services, and auditing functions, etc.) and that the organization is not required to agree to the
restriction requested.
By signing this form, I consent to the use and disclosure of protected health information about me for
the purpose of treatment, payment and healthcare operations. I have the right to revoke this consent, in
writing, except where disclosures have already been made in reliance on my prior consent.
This consent is given freely with the understanding that:
1.Any and all records, where written or oral in electronic format, are confidential and cannot be
discussed for reasons outside of treatment, payment or healthcare operation without my prior written
authorization, except as otherwise provided by law.
2.A photocopy or fax of this consent is as valid as the original.
3.I have the right to request that the use of my protected health information, which is or disclosed for
the purposes of treatment, payment or healthcare operations, be restricted. I also understand that
Women's Care of Mid Cities and I must agree to any restriction in writing that I requested on the use
and disclosure of my protected information which have been previously agreed upon.
