Thank you for choosing Delta Clinical Services . Please review the form below so we can provide the optimal care for you, bill appropriately, and share your information securely.
CONSENT FOR TREATMENT
By signing this form, I consent to and authorize my provider(s) Marco R. Middleton Sr. to treat me or my dependent. I understand this could include lab tests, , immunizations, medication prescription and/or administration, education, other diagnostic tests, or behavioral health interventions. My provider may also bill for cognitive services such as disease state monitoring, medication education and general healthcare screenings such as height, weight, blood pressure and oxygen saturation. I understand that my provider is available to explain the treatment and I have the right to refuse treatment. I understand that this consent will be valid and remain in effect as long as I attend any of the clinics at Delta Clinical Services.
CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION
I hereby authorize Delta Clinical Services to release any information acquired in the course of my examination and treatment to any authorized agent for the purposes of healthcare, treatment, and payment. I authorize the release of medical, dental, and/or behavioral health information to my insurers as necessary for determination and payment of benefits; to utilization review and professional standards review organizations, companies, and community resources that assist me with my healthcare needs.
NOTIFICATION OF PRIVACY
Delta Clinical Services complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I have received the Delta Clinical Services Notice of Privacy Practices and Medicare Patients’ Bill of Rights.
CONSENT TO BILL, ASSIGNMENT OF BENEFITS, AND PAYMENT
I authorize Delta Clinical Services to file a claim with my insurance carrier for services rendered. I authorize payment of benefits directly to Delta Clinical Services, for services provided to my dependent or me. I understand that I am NOT responsible for any part of the charges that are not covered/paid by my insurance. I recognize that the billing statements and EOB’s will have the specific name of our clinic and that of our Collaborative Practice Physician. I understand that I may revoke this consent in writing; however, my revocation will not apply to information already used or released in reliance on this consent. I agree that a copy of this consent may be used in place of the original. I also understand that by refusing to sign this consent or revoking this consent, this organization may not be able to provide services to me. My signature below indicates that I understand and accept the content of this form.
