PRACTICE POLICIES

ASSIGNMENT OF BENEFITS AND INFORMATION RELEASE

I AUTHORIZE the release of any medical information, including without limitation, information related to psychiatric care, drug abuse, alcohol abuse, or HIV/AIDS confidential information that is needed for submission to my insurance carrier in order to process a claim or for utilization review or quality assurance activities.

I ASSIGN all medical and/or surgical benefits including major medical benefits to which I am entitled to Brandon Area Primary Care. A photocopy of this authorization shall be effective and valid as the original.

I AGREE to accept responsibility for any balance remaining after insurance pays or, if an HMO participant, any appropriate co-payment, deductible, or non-covered service. If I do not have insurance coverage, I agree to adhere to payment arrangements made at the time of my appointment, and to be responsible for any legal fees, cost, and expenses incurred by myself in the pursuit of the collection of fees due them for service provided. I understand that this form or a copy thereof is valid for twelve (12) months.

CONTACT AUTHORIZATION

In accordance with ACA (The Association of Credit and Collection Professionals) per the Telephone Consumer Protection Act you agree, in order for us to render service to you and access your account or to collect any amounts you may owe in the event there are charges not covered under your insurance company. We may contact you by phone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you (by your wireless carrier).We may also contact you by sending text messages or e-mails address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.