FORM #5 - PATIENT CONSENT / ACKNOWEDGEMENT

  • Patient Consent / Acknowedgement

  • CONSENT TO ASSESSMENT AND RIGHTS AND RESPONSIBILITIES: By signing this form, I acknowledge the understanding of the services provided by Temah Healthcare Services, LLC (THS). By presenting myself for health care services, I authorize and consent to the performance of any and all assessments, test, treatments, and diagnostic procedures which may be ordered by THS, it associated providers, clinicians, and other personnel as is necessary in his or her professional judgement.  I am aware that among those that may be caring for me are medical, nursing, and other health care personnel who are in training and I consent to their involvement in my care. I understand that medicine is not an exact science and no guarantees have been made as to the result of treatment or examination.  I understand that the services provided by THS are supplementary to my existing medical care and are limited to scheduled in-home evaluation and management of medical conditions which lend themselves to outpatient, non-acute treatment. I understand that the providers at THS will communicate with me by phone, e-mail or fax, but that they will not always be immediately available, and that a response to my communication may take up to 48-72 hours.

     

    NOTICE OF PRIVACY:

    I acknowledge that I have been offered a copy of the Notice of Privacy Practices, I further understand that the Notice of Privacy Practices describes how THS may use or disclose my confidential medical information in providing care to me. In doing so, I am consenting to the use and disclosure of health information about substance abuse, mental/psychiatric care, or HIV status. If applicable, I consent to the release of health information about me to my insurer or other third party payers and any agent or consultant that helps THS in getting paid or assist in my treatment or it health care operations. I can revoke my consent in writing at any time except to the extent that THS has already relied on my consent.

     

    RELEASE OF MEDICAL RECORDS:

    I consent to release my hospital and/or physician/other provider records to THS. I understand that THS will maintain a confidential health record that contain information concerning my demographics and medical condition. I further authorize THS to release copies of my medical records as necessary to other health care providers, facilities, or regulatory or accrediting bodies for the purpose of continuing and coordination of my treatment plan, quality assurance, and survey and accreditation purposes.

     

    ASSIGNMENT OF BENEFITS & PAYMENTS AGREEMENT:

    I, the undersigned authorize Temah Healthcare Services (THS) to release all information necessary for filing and securing a claim with any insurance company or group. This includes my medical information. I authorize payment of benefits to Temah Healthcare Services directly for services rendered. I permit a copy of this authorization to be used in place of the original. I may revoke this authorization at any time in writing.

     

    I fully understand that I, as guarantor, am financially responsible to THS for any charges not reimbursed by my health insurance including and not limited to deductibles and/or copays.  I will receive an Advance Beneficiary Notice for all deductibles, copays, and fees for non-covered services not covered by Medicare and I will be responsible for payments.  If I have no insurance, I hereby assume(s) full responsibility for and agree(s) to pay all costs, charges, and expenses of every description incurred by me in full amount billed to THS. If my insurance requires a referral and I do not bring one, I will be responsible for payment.

     

    FINANCIAL POLICY

    It is your responsibility to provide complete and accurate insurance information to our office staff. Your insurance policy is a contract between you and your insurance company. Please bring your insurance card at each visit. As a consideration, we will gladly submit a claim to your insurer. You must inform the office of all insurance changes, authorizations, and referral requirements. In the event that office is not informed, you will be responsible for any charges denied. If your insurance company does not pay the office with a reasonable period of when the claims is made, we will look to you for payment and /or assistance with your insurance company.

     

    Health plans are not the same and do not cover the same services. In the event your health plan determines service to be “not covered”, or you do not have authorization, you will be responsible for the complete charge. Patients are encouraged to contact their insurance companies for clarification of benefits prior to services rendered.

     

     

    CO-PAYS, DEDUCTIBLES, AND CO-INSURANCE

    Unfortunately, we unable to waive co-pays, deductibles, or co-insurance amounts. Contractually, we are required by your insurance company to collect the portion for which you are liable at the time the services are rendered. Payment made at the time of service allows us to keep administrative cost to a minimum. There is a $25 fee for returned checks.

     

    PAYMENT PLANS

    Payment plans are available under certain circumstances. In that event, an advance notice and pre-authorization is necessary. We also have sliding scale payment fee schedule for those who meet the qualification criteria. Please contact our office for further information. It is a pleasure to help you.

     

    ACCOUNTS DUE

    No extension, indulgences or forbearances will be granted to any patient. Every attempt will be made including the services of a collection agency, to collect past due accounts. In the event that this obligation remains unpaid and requires referral for collection, the undersigned agrees to pay all cost of collection including and not limited to reasonable attorney’s fees. Past due accounts are transferred to the collection agency after 90 days.

     

    MISSED APPOINTMENTS AND APPOINTMENTS

    One priority at Temah Healthcare services is to provide quality and patient-centered care. We are mindful that your time is valuable and that circumstances may arise that may not allow you make your appointment. Keeping your appointment and preventing no-shows ensures that you get the care you deserve and affords others to do the same. If you are unable to keep your appointment, it is required that you give a 24-hour notice. Any cancellation without a 24 hour notice or any missed appointment will result in a broken appointment fee of $40 for new appointments and $30 for return appointments. We hope to avoid these circumstances, but we wanted to bring them to your attention.

     

    Temah Healthcare Services visits their patients according to geographical locations, therefore scheduling a patient could possibly take up two (2) weeks after receiving and verifying all completed forms. Due to traffic and other unforeseen circumstances, we do not give specific times for appointments. Our patients are home-bound. We only give dates and a time range which is between 8:30-5:30, however, these times may fluctuate due to circumstances beyond our control. It is our policy that after three (3) missed appointments we reserve the right to discharge you from Temah house call program.

     

    MEDICAL RECORDS

    An authorized written request is required for copies of medical records. Our fees are in accordance with Maryland State Law. Please allow 7-10 days for processing.

     

    BILLING OFFICE AND QUESTIONS AND CONCERNS

    You can call 240-280-1394 between 9am-3pm for any billing questions, inquires, resolution of billing issues or concerns. Please know that there is usually a 3-5 business day delay in receipt of your insurance information after you have received you copy. As a result, allow 3-5 business day for a response.

     

    All payments and/or correspondence should be mailed to: Temah Healthcare Services, LLC

           5310 Old Court Road

           Suite 303

           Randallstown, MD 21133

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