• Diagnosing or providing treatment to me;
• Obtaining payment for my health care bills; and
• Conducting health care operations such as quality assessment and improvement activities, case management and care coordination with other providers.
“Protected Health Information” means and includes my health information, as well as my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer, or a health care clearinghouse. This Protected Health Information relates to my past, present, or future physical or mental health condition and which identifies me or may be used to identify me.
I understand that diagnosis or treatment of me by Integral or an affiliated company may be conditioned upon my consent as evidenced by my signature on this document.
Notice of Privacy: I have received and reviewed Integral’s Notice of Privacy Practices prior to signing this document. I understand that Integral reserve its right to change the privacy practices that are described in the Notice of Privacy Practices. Furthermore I understand that I may obtain a revised notice of privacy practices by contacting Integral and requesting one.
Revocation of Consent: I understand that I have the right to revoke this consent, in writing, at any time, except to the extent that Integral has already provided services or otherwise taken action in reliance on this consent.
Payment and Billing: I request that payment for all covered benefits regarding any services furnished to me by Integral be made to Integral. I understand that Integral shall bill an appropriate insurer or third party payer when appropriate as a courtesy to me. I authorize any holder of Protected Health Information to release to the Centers for Medicare and Medicaid Services and its agents or my insurance company any information needed to determine benefits which may be available. The fact that I may have insurance does not release me of my personal responsibility for payment. I agree to be responsible for payment of charges for services rendered to me by Integral that are not otherwise covered or paid for by Medicare or any other health insurance plan I may have. I hereby agree that in the event I receive payment directly from any health insurer or other payor that I will immediately forward the amount of such payment due on my account to Integral or its authorized assignee.
Print Name ___________________________________________ Date _________________
Patient Signature: __________________________________________________________________
(or Authorized Agent Signature)