HEALTHFIRSTPrint Name:
FAMILYCARE CENTER, INC.Date of Birth:
AUTHORIZATION AND CONSENT FOR TREATMENT, PAYMENT,
AND HEALTHCARE OPERATIONS
This health care facility will use your health care information for the following reasons:
Treatment: We will use your health information to make decisions about the provision, coordination or management of your healthcare, including analyzing or diagnosing your condition and determining the appropriate treatment for that condition. It may also be necessary to share your health information with another healthcare provider whom we need to consult with in respect to your care.
Payment: We may need to use or disclose information in your health record to obtain reimbursement from you, from your health insurance carrier, or from another insurer for services rendered to you. This may include terminations of eligibility or coverage under appropriate health plans, pre-certification and pre-authorization of services or review of services for the purposes of reimbursement. This information may also be used for billing, claims, management and collection purposes, and related healthcare data processing through our system.
Operations: Your health records may be used in our business planning and development operations, including improvements in our methods of operation, and general administrative functions. We may also use the information in our overall compliance planning, healthcare review activities and arranging for legal and auditing functions
Consent for Treatment: This consent is for ongoing healthcare, until I no longer request services or until I may no longer be eligible for services through HealthFirst Family Care Center, Inc.
I understand that consent includes: general physical collection of samples for necessary blood and urine tests; examination of mouth, ears, genitals, mucus membranes and skin; repair of small cuts; and, other ordinary clinic procedures. I understand that I may revoke this consent only by giving a written statement and that, if I choose to revoke this consent, the possible medical consequences of my decision will be explained to me.
I hereby agree to allow any healthcare information to be used for the purpose of treatment, payment and healthcare operations.
I further agree and hereby give permission for HealthFirst Family Care Center, Inc. physician and staff to examine me (or the above named patient) to conduct such tests and procedures as are necessary for diagnosis and care, and to give such treatment as the clinical physician deems necessary.
SignatureDate
Revised 1/2016