New Patient Registration

Medical Insurance Information

Assignment of Benefits, Informed Consent, And Authorization to Release Medical Records

I hereby authorize Wayne Radiology Center, and its associates and assignees to apply for Medicare and other health insurance benefits (if applicable, PIP and workmen’s compensation) on my behalf. I request payments be made directly to the above provider. I certify that the information I have reported with regard to my insurance carrier(s) is correct. I authorize the release of medical information about me to my health insurance carrier and HCFA (Health Care and Finance Administration) agents, any and all other information needed to determine the benefits payable for related service(s).

I hereby authorize payments of Medical benefits be made on my behalf to the above named provider. I release any holder of Medicare information about me to my insurance carrier(s) necessary to determine benefits payable for related services.

I hereby authorize Wayne Radiology Center, its associates, and assignees to provide treatment and/or examination. I understand the reasons why this/these procedure(s) is/are necessary, its advantages and possible risks. Despite me being told of these risks, I still desire to have and do consent to this/these procedure(s). I also authorize Wayne Radiology Center to RELEASE AND OBTAIN any MEDICAL RECORDS, pertinent to  my examination or treatment
to and from my physician, hospital, insurance company, adjuster, or attorney if applicable in this case. 

Patient Release Form

MUST BE SIGNED BY PATIENT OR IF THAT PATIENT IS A MINOR, THE LEGAL GUARDIAN.

I certify that the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare) for the purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I understand I am responsible for co-insurances, copayments and deductibles. If I am not insured or Wayne Radiology Center does not participate in my plan, I am responsible for payment in full at the time of service.

I certify that I hereby authorize Wayne Radiology Center, its providers and staff to provide my minor child in my absence with examinations and basic treatments following the initial visit for which additional consents are not required. I understand additional written consent may be necessary for these types of procedures and that the legal guardian must be present for such consent.

Policy Regarding Patient Financial Responsibility

The following is a summary of our financial policy. We would be happy to provide further clarification if necessary. We ask that you read and sign the following to acknowledge that you have been advised of your financial responsibility for medical services provided here.

*Please initial each item and sign below*

HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguard to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.

What is this all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, email, US mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
6. Your confidential information will not be used for the purpose of marketing or advertising of products, goods or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.