General Consent for Care and Treatment Consent

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services .

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Signature of Patient or Personal Representative	Date:

Printed Name of Patient or Personal Representative	Relationship to Patient

Printed Name of Witness	Employee Job Title

Signature of Witness	Date

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1.	I hereby authorize  Zam Zam Family Clinic to obtain the Protected Health Information or release the information:

Patient Name: - - - - - - - - - - - - - - -
Telephone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date of Birth: 	_ Last 4 of SSN: xxx-xx-_ _ _ _ _ _ _

2.	Person(s) or Entity Authorized to Receive the Disclosure. Name or specifically describe the persons/organizations
(or the classes of persons and/or organizations), including us, (1) who you are authorizing to make use of the protected health information described below and who you are authorizing to disclose the protected health information described below, and (2) to whom you are authorizing the disclosure and subsequent use of the protected health information described below.
TO:	Zam Zam Family Clinic	FROM:

Name of Healthcare Provider/ Other

965 Oakland Road Bldg 3 Suite D

Name of Healthcare Provider/ Other

 	
Street Address	Street Address

Lawrenceville , GA 30044 City , State , Zip Code

City, State, Zip Code

770-807-0061
Phone

770-733-1131	 	    	
Fax	Phone	Fax

3.	Protected Health Information to be used or disclosed. Specifically and meaningfully describe the protected health information you are authorizing to be used and/or disclosed:
D My health information  relating to the following treatment or condition: _  _  _  _  _
0	My health records for the following date(s) :_  _   _   _   _   _   _   _   _   _   _  _   _ _
0	Most recent 		years of record
0	Complete health record:
C Include:0	Exclude: My health information related to psychiatric or psychological conditions or treatment, except psychotherapy notes; alcohol and drug abuse; sickle cell anemia; and acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV) .
0	Immunization Record
0	Last Physical
0	Other information to be used or disclosed (describe information in detail):

4.	Purpose of use or disclosure:
0	Treatment, Payment, or Healthcare Operations
O. Transfer of Care
D Personal Use
D Disclosure to Life Insurer for Coverage Purposes
D Disclosure to Employer of results for pre-employment physical or lab tests
D Other (describe each purpose of the requested use/disclosure in detail):
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5.	If not previously revoked, this Authorization will expire within 1 year from the date listed or D upon the happening of the following event: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

V. 05.19 Form may not be altered without permission

Patient or Personal Representative MUST receive a copy of this form once completed

(Page 2 of2)

Authorization and Signature: I authorize the release of any confidential protected health information, as described in my directions above. I have had the opportunity to read and consider the contents of this authorization. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. I further understand that
refusing to sign this authorization will not affect my treatment, payment, enrollment, or eligibility for benefits. I understand that I may revoke
I	this authorization in writing, except for any actions already taken based upon it. The information that is used and/or disclosed pursuant to this
authorization may be redisclosed by the recipient unless the recipient is covered by federal or state laws that limit the use and/or disclosure of my confidential protected health information.

Signature of Patient or Personal Representative:	Date: 	_

Relationship if Personal Representative: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

The following specifies your rights about this authorization under the Health Insurance Portability and Accountability Act of 1996, as amended from time to time ("HIPAA").

1.	Tell your provider if you do not understand this authorization, and the provider will explain it to you.
2.	You have the right to revoke or cancel this authorization at any time, except: (a) to the extent information has already been shared based on this authorization; or (b) this authorization was obtained as a condition of obtaining insurance coverage. To revoke or cancel this authorization, you must submit your request in writing to Zam Zam Family Clinic at the following address: Attn: Practice Administrator,965 Oakland Road Bldg 3 Suite D Lawrenceville, GA 30044. Unless otherwise revoked, this authorization will expire as indicated on page 1 or within one year from the time the form was signed.
3.	You may refuse to sign this authorization . Your refusal to sign will not affect your ability to obtain treatment, payment, enrollment or your eligibility for benefits. However, you may be required to complete this authorization form before receiving treatment if you have authorized your provider to  disclose  information  about  you  to a  third party. If  you  refuse to  sign  this authorization  ,  and  you  have authorized your provider to disclose information about you to a third party, your provider has the right to decide not to treat you  or accept you as  a patient in their practice.
4.	Once the information about you leaves this office according to the terms of this authorization , this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIP AA. If the person or entity receiving this information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations.
5.	You may inspect or copy the protected health information to be used or disclosed under this authorization. You do not have the right of access to the following protected health information: psychotherapy notes, information compiled for legal proceedings, laboratory results to which the Clinical Laborato1y Improvement Act ("CLlA") prohibits access, or information held by certain research laboratories. In addition , our provider may deny access if the provider reasonably believes access could cause harm to you or another individual •in some of these circumstances , an _individual has a right to have the denial reviewed by a licensed health care professional designated by the covered entity who did not participate in the original decision to deny.
6.	If this office initiated this authorization, you must receive a copy of the signed authorization.
7.	Special Instructions for completing this authorization for the use and disclosure of Psychotherapy Notes, HIP AA provides special protections to certain medical records known as "Psychotherapy Notes."  All Psychotherapy  Notes recorded on any  medium   by a  mental health professional (such as a psychologist or psychiatrist) must be kept by the author and filed separate from the rest of the client's medical records to maintain a higher standard of protection. "Psychotherapy Notes" are defined under  HIPAA as notes recorded  by a health care provider who is a  mental health  professional   documenting or analyzing the contents of conversation   during a private counseling  session  9r a group, joint or family counseling session and that are separate from the rest of the individual's medical records. Excluded from the "Psychotherapy Notes" definition are the following: (a) medication prescription and monitoring, (b) counseling session start and stop ti mes ,
(c)	the modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of: diagnosis, functional status; 'the treatment plan, symptoms, prognos is , and progress to date. Except for limited circumstances set forth in H IPAA , in order for a medical provider to release "Psychotherapy Notes" to a third party, the client who is the subject of the Psychotherapy Notes must sign this authorization to specifically allow for the release of Psychotherapy Notes.
8.	You have a right to an accounting of the disclosures of your protected health information by the provider or its business associates. The maximum disclosure accounting period is the six years immediately preceding the accounting request. The provider is not required to provide an accounting for disclosures: (a) for treatment, payment, or health care operations; (b) to you or your personal representative;
(c)	for notification of or to persons involved in an individual's health care or payment for health care, for disaster relief, or for facility directories; (d) pursuant to an authorization; (e) of a limited data set; (t) for national security or intelligence purposes; (g) to correctional institutions or law enforcement officials for certain purposes regarding inmates or individuals in lawful custody; or (h) incident to otherwise permitted or required uses or disclosures. Accounting for disclosures  to health oversight agencies and law enforcement officials must be temporarily suspended on their written representation that an accounting would likely impede their activities .

Patient or Personal Representative MUST receive a copy of this form once completed.

Registration, Billing and Collection Payment Policy

We are participating with Medicare, Georgia Medicaid, and most Managed Care plans in the area. We will file these claims for you. Patients are expected to pay any deductibles, coinsurance or copay amounts owed at the time of service.

If you are a Medicare patient and do not have a supplemental plan or a Medicare Advantage plan, you are responsible for payment of the annual deductible , co-insurance and non-covered services at the time of service.
Patients with a third party coverage with whom we do not contract are responsible  for  payment  in  full  at the time  of service. As a courtesy, we will  file  your charges  with this third  party  payer upon   receipt  of payment   in full.  Otherwise,   we will provide you with a completed third party payer claim form to use in filing your insurance.

Patients with a High Deductible Health Plan that have not met their annual deductible amount on the date of service will be asked to pay SoFHA's estimate of the allowed charges at the time of service. You will be billed for any additional deductible amounts after the insurance processes the claim.

Patients without verifiable insurance will be responsible for payment of all services rendered at the time of service.

We accept cash, check, Visa, MasterCard. In an effort to simplify  the  payment  process, we provide  a convenient.  highly secure Credit/Debit/HSA card and Bank ACH payment program. You will be asked to provide a card-on-file (card/ACH-based) assurance at the time of service . After the insurance claim has  been  filed (if applicable),  we  will send you an electronic bill of your final financial responsibility . Your card-on-file will be charged for your  out-of­  pocket responsibility after the notice period and an electronic receipt will be emailed to you.

Please realize , however , that:

l.		Your insurance is a contract between you and your insurance company. We are not a party to that contract. You are responsible to know your insurance benefits and the portion you will be liable for.

2 .	Depending on the specifics of the agreement we have with your insurance company , any portion of our fees not
/	covered may be the responsibility of the patient/guarantor.
3.	Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. Any service not covered is the responsibility of the patient/guarantor.

Regardless  of insurance  payment, the patient and/or guardian  remains  responsible  for all financial  obligations  incurred  at the time of service. We realize that some balances may not  be able to be  paid  in  full at time  of service  and  we  will  be  happy to assist you in making payment arrangements.

By signing this financial policy acknowledgement of the financial.responsibility is accepted. This will remain in effect until revoked in writing.

Patient Name	Patient Date of Birth

Patient or Guardian Signature	Date