Occupational Medicine

Authorization for Release of Medical Records and Reports

I hereby authorize the use or disclosure of my individually identifiable health information as described below. A photo copy of this authorization shall be given the same force and effect as the original.

Patient/claimant name

Address

Date of birth

Social security #

Persons/organizations providing information include:

Any health care providers who have provided treatment to me at any time
Physicians Quality Care

Persons/organization receiving information: (including its representatives, case managers, and attorneys)

Specific description of information:
All information, oral and written, including, but not limited to copies of medical records and reports concerning my past, present or future physical, mental, or emotional condition and treatment thereof. I authorize health care providers to meet with and/or discuss all aspects of my treatment including but not limited to diagnosis/prognosis, return to work, causation, or any issue regarding any aspect of my treatment and injury

Specific description of the purpose of use or disclosure:
For the administration of my claim against employer.

This authorization will expire upon the final resolution of my claim

I understand that:

I may revoke this authorization at any time by notifying the providing organization in writing, unless action had been taken in reliance on my authorization.
The information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
I waive any implied covenant of confidentiality with healthcare providers that I have regarding my medical treatment.
My healthcare provider may not condition treatment on the signing of this authorization, unless the care provided was solely for the purpose of creating health information to be provided to the contact below:
I have the right to refuse to sign this authorization. However, I am aware that the contact below can condition payment of my claim on the execution of this authorization and that in the event of a litigated claim, information may be released pursuant to state and federal law even if I refuse to sign.

Patient Name

Guardian Name

If patient is a minor

Date

NOTICE OF PRIVACY PRACTICES

We keep a record of health care services we provide you. We will not disclose your records to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may get more information by contacting our Medical Records Department. I hereby acknowledge that I have received a copy of Physicians Quality Care's HIPAA Notice of Privacy Practices.

BILLING/FINANCIAL POLICY

Our office is committed to providing quality and cost-effective healthcare to our patients. It is your responsibility as the patient and/or guarantor to know and understand what services are covered by your insurance and obtain all authorizations prior to your appointment. Your provider may recommend services that he/she feels are beneficial but may not be covered by your insurance. It is your responsibility to provide us with your most current billing information as well as your most current insurance information. Insurance reimbursement is a contract between you and your insurance company. As a courtesy to you, we file all claims for you. You will be responsible for all copays, deductibles, co-insurance amounts along with the entire amount of any non-covered services. Payment for your copay or deductible will be required prior to being seen by one of our physicians. Any additional balance will be billed to the address given at the time of check in. If you have any questions or wish to dispute any balance, it is your responsibility to contact our billing office within thirty {30) days after the receipt of the initial statement. Balances not paid in full with thirty (30) days of the statement issue date are deemed past due. If you are not able to pay the balance in full, you must contact our billing office to set up payment arrangements. If your account is deemed past due and/or regular monthly payments are not being made on the account, we may refer your account to Fox Collection Agency. Once referred to Fox, you will be responsible for any collection fees, attorney fees, court costs, etc. Once your account has been turned over to Collections, Physicians Quality Care reserves the right to deny treatment for you or anyone under your care until the balance is paid in full

SELF PAY POLICY

Patients who do not have insurance coverage (or proof of insurance) or who choose to pay for non-covered services are required to pay a $125 deposit at the time of service. This is not the cost of the office visit, but only a deposit. If any additional charges are incurred, they will be billed to the patient at a 25% discounted rate. Due to government regulations, it is considered fraudulent for us to accept payment from TennCare recipients for medical expenses.

Patient Forms

I understand that:

NOTICE OF PRIVACY PRACTICES

BILLING/FINANCIAL POLICY

SELF PAY POLICY