HIPAA AUTHORIZATION FORM.docx LIEN MMC.docx LIEN MMIPP.docx MEDICAL RECORDS RELEASE INFO.doc PATIENT AND AUTO INFO.docx PATIENT HEALTH INFO.docx
HIPAA AUTHORIZATION FORM (Health Insurance Portability and Accountability Act) Patient Name SSN: Date of Birth I hereby authorize the release of health information to Mountain Medical Injury and Pain Prof LLC, its billing organization, medical associates, Mountain Medical Care and my Attorney of record: Attorney or Law Firm: To obtain medical records for my personal injury Purpose of Release: and/or workers compensation case due to injuries sustained on or about: Date of Injury: I understand that the information disclosed pursuant to this authorization may be re-disclosed to additional parties and no longer protected by HIPAA I understand that the released may include information pertaining to the following condition(s): drug/alcohol abuse, psychological conditions, HIV, or an AIDS related condition I certify that this request has been made voluntarily: I understand that I have the right to inspect and obtain a copy of any information disclosed pursuant to this authorization: initial: initial initial initial Signature: CONSENT FOR TREATMENT Or CONSENT FOR TREATMENT OF A MINOR I hereby authorize the above referenced providers and whomever they designate as assistants to administer treatment as necessary for the care of myself or a minor that I have authority over. I understand that the practice of medicine is not an exact science and there are no guarantees of the results. Every individual may respond differently to a particular treatment regimen. I understand that there are certain risks associated with an examination or treatment and those risks have been presented and explained to me. Patient or Guardian Signature: Date:
LIEN ASSIGNMENT AND AUTHORIZATION FOR MOUNTAIN MEDICAL, LLC This agreement entered into this date between Patient and Mountain Medical Care; "MMC" and all Health Care Providers contracted with MMC. The Patient desires to receive health care services from MMC and Health Care Provider(s) and desires to provide a lien assignment and release to MMC and Health Care Provider(s) as consideration for the MMC and Health Care Provider(s) awaiting payment. Accordingly, it is agreed: A. Patient agrees to have a lien placed on any settlement, judgment or payment from any legally responsible party or insurance company arising from injuries related to a legal claim for damages from an incident on or about, including, but not limited to, a bodily injury liability claim, an uninsured or underinsured motorist medical payment coverage or any other insurance or legal claim. This lien is granted to MMC and Health Care Provider(s). Patient agrees and instructs any insurer making medical payment on their behalf to make any check or draft payable to Mountain Medical Care, LLC. I understand that regardless of the outcome of my case I am directly and fully responsible to MMC and Health Care Provider(s) for all bills submitted for services rendered and this agreement is made solely for additional protection and consideration for awaiting payment. Patient further understands that such payment is not contingent on any settlement, claim, judgment or verdict which patient may eventually recover. In the event of non-payment or reduced payment by any insurance company, health care benefit plan or any other party possibly liable to patient for payment of health care costs incurred as a result of services rendered by MMC and Health Care Provider(s). Patient agrees to be responsible for any such outstanding balance, including interest accrued at a rate of 9% per annum. B. Patient fully understands and agrees that this lien assignment and authorization is irrevocable. C. Patient agrees and directs any Attorney to honor this lien and make payment under the lien directly to MMC and Health Care Provider(s). Patient directs that their Attorney be bound by this lien and treat it irrevocably as an assignment due to MMC and Health Care Provider(s). D. Patient agrees that in the event they receive any check or draft subject to this agreement; patient agrees to act as fiduciary agent for the Heath Care Provider(s) and will immediately deliver the check or draft to MMC, which will be applied to debt for services rendered. E. Patient authorizes and directs their Attorney to disclose any settlement or collected judgment amounts, distribution sheet and final accounting by patients Attorney to MMC and Health Care Provider(s) and waives any Attorney/Client privilege as it relates to any terms, distribution and final accounting of any funds collected. F. Patient authorizes and directs any third party insurance company to disclose the settlement amounts, dates ofsettlement and terms to MMC and Health Care Provider(s). G. Patient assigns to MMC and Health Care Provider(s) any and all benefits and payments payable by Patients insurance or health care plan(s) as a result of charges incurred by patient for services rendered by MMC and Health care Provider(s). Patient also assigns to MMC and Health care Provider(s) any and all contractual rights and legal causes of action against an insurance company, health care plan or any other party liable to patient for payment of health care costs incurred as a result of services rendered by MMC and Health Care Provider(s). H. Patient authorizes MMC and Health Care Provider(s) to receive a complete copy of Patients Insurance policy including any endorsements, conditions, limitations, benefits, exclusions and policy limits. I. This lien is subordinate to any Attorneys fees and costs. Fax or email to: 206-350-8698 mountainmedicalcare@gmail.com I hereby agree to provide limited Power of Attorney to Mountain Medical Care LLC. I will endorse my name for all checks made payable to me or jointly to the business and personally for health care service provided. Patient Signature: Date: Patients Attorney confirmation of receipt: Please complete and forward back The Attorney for the patient received a copy of this lien on Date: Attorney Signature:
LIEN ASSIGNMENT AND AUTHORIZATION FOR MOUNTAIN MEDICAL, LLC This agreement entered into this date between Patient and Mountain Medical Injury and Pain Professionals "MMIPP" and all Health Care Providers contracted with MMIPP. The Patient desires to receive health care services from MMIPP and Health Care Provider(s) and desires to provide a lien assignment and release to MMIPP and Health Care Provider(s) as consideration for the MMIPP and Health Care Provider(s) awaiting payment. Accordingly, it is agreed: A. Patient agrees to have a lien placed on any settlement, judgment or payment from any legally responsible party or insurance company arising from injuries related to a legal claim for damages from an incident on or about, including, but not limited to, a bodily injury liability claim, an uninsured or underinsured motorist medical payment coverage or any other insurance or legal claim. This lien is granted to MMC and Health Care Provider(s). Patient agrees and instructs any insurer making medical payment on their behalf to make any check or draft payable to Mountain Medical Injury and Pain Professionals, LLC. I understand that regardless of the outcome of my case I am directly and fully responsible to MMIPP and Health Care Provider(s) for all bills submitted for services rendered and this agreement is made solely for additional protection and consideration for awaiting payment. Patient further understands that such payment is not contingent on any settlement, claim, judgment or verdict which patient may eventually recover. In the event of non-payment or reduced payment by any insurance company, health care benefit plan or any other party possibly liable to patient for payment of health care costs incurred as a result of services rendered by MMIPP and Health Care Provider(s). Patient agrees to be responsible for any such outstanding balance, including interest accrued at a rate of 9% per annum. B. Patient fully understands and agrees that this lien assignment and authorization is irrevocable. C. Patient agrees and directs any Attorney to honor this lien and make payment under the lien directly to MMIPP and Health Care Provider(s). Patient directs that their Attorney be bound by this lien and treat it irrevocably as an assignment due to MMIPP and Health Care Provider(s). D. Patient agrees that in the event they receive any check or draft subject to this agreement; patient agrees to act as fiduciary agent for the Heath Care Provider(s) and will immediately deliver the check or draft to MMIPP, which will be applied to debt for services rendered. E. Patient authorizes and directs their Attorney to disclose any settlement or collected judgment amounts, distribution sheet and final accounting by patients Attorney to MMIPP and Health Care Provider(s) and waives any Attorney/Client privilege as it relates to any terms, distribution and final accounting of any funds collected. F. Patient authorizes and directs any third party insurance company to disclose the settlement amounts, dates of settlement and terms to MMIPP and Health Care Provider(s). G. Patient assigns to MMIPP and Health Care Provider(s) any and all benefits and payments payable by Patients insurance or health care plan(s) as a result of charges incurred by patient for services rendered by MMIPP and Health care Provider(s). Patient also assigns to MMIPP and Health care Provider(s) any and all contractual rights and legal causes of action against an insurance company, health care plan or any other party liable to patient for payment of health care costs incurred as a result of services rendered by MMIPP and Health Care Provider(s). H. Patient authorizes MMIPP and Health Care Provider(s) to receive a complete copy of Patients Insurance policy including any endorsements, conditions, limitations, benefits, exclusions and policy limits. I. This lien is subordinate to any Attorneys fees and costs. Fax or email to: 206-350-8698 mountainmedicalcare@gmail.com I hereby agree to provide limited Power of Attorney to Mountain Medical Care LLC. I will endorse my name for all checks made payable to me or jointly to the business and personally for health care service provided. Patient Signature: Date: Patients Attorney confirmation of receipt: Please complete and forward back The Attorney for the patient received a copy of this lien on Date: Attorney Signature:
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS I hereby request and authorize the release of my personal health information to: Mountain Medical Care Nancy A. Smith, PA-C and Mary Nolan MD, 5534 Salvia Ct Golden Co 80403 303-596-7122 Scan to: MountainMedicalCare@gmail.com (preferred) Or Fax to: 206-350-8698 TREATMENT DATES: From the date of to the present. TREATING FACILITY: Address Phone STAT: Please send all records, including diagnostic studies, such as X-rays, CT's, MRI, blood work etc. He/She was seen at your facility for injuries sustained in an automobile accident on or about: AUTHORIZATION: I certify that this request is made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this authorization at any time in writing by sending a letter to the facility Privacy Officer or their designee. I understand my revocation will not be effective to the extent that action has already been taken in reliance on it. This authorization expires: If not otherwise specified this authorization will expire in 365 days.. Other Condition: A copy or facsimile of this Authorization with my signature may be used with the same validity as the original. Patient: Birthdate: SS#: Date of Injury: Treatment Date Patient s Signature X: Date:
CAR INSURANCE INFORMATION: List the following information on the car in which you were driving or riding in: Owner of Vehicle: Type of Vehicle: Insurance Company: Insurance Company Phone Number: City: State: Zip Code Policy Number: Claim Number: Adjusters Name: Med Pay Limits: Uninsured Motorist Limits: OTHER AUTO INSURANCE: Does any Relative living with you have Auto Insurance? (Sibling, Parent, Cousin, Grandparent) Insurance Company: Policy Number: Agents Name: Phone Number: Med Pay Limits: Uninsured Motorist Limits: DRIVER AT-FAULT INFORMATION: Name of At-Fault Driver: Phone Number: Insurance Company of At-Fault Driver: Insurance Phone Number: ATTORNEY INFORMATION: Name of Attorney: Contact Person: Address: City: State: Zip Code: Attorney Phone Number: Attorney Email:
PATIENT INFORMATION Patient Name: Sex: Marital Status: Date of Birth: Social Sec. No. Address: City: State: Zip: Home Phone: Mobile Phone: Email: Employer: Phone: Emergency Contact Name: Home Phone: Mobile Phone: Relation: Referred by: Sales Provider Friend PERSONAL MEDICAL INSURANCE INFORMATION: Insurance Company: Group Number: Policy Number: Insurance Phone Number: Claims Address: Type of Policy: (please circle one of the following) PPO HMO *************************************************************************************************** CONSENT FOR TEST RESULTS: I give Mountain Medical permission to leave all Imaging/Lab results, appointments and other medical information and advice on (circle below all that apply) Voicemail at Work/Home/Cell OR DO NOT LEAVE MESSAGE OR Email Okay to leave message with family member? ( If so, List name and relation) Okay to receive Email appointment reminders? Y/N Specials or promotions? Y/N Please phone 24 hours prior to a scheduled appointment to cancel or reschedule an appointment or you will be charged 1/2 of the price of scheduled visit. You will be required to pay for missed appointments at your next appointment. We honor Credit, Check or Cash for visits. If a check or credit card payment is returned you will be charged $35 and must pay in cash in the future. All unpaid charges are due before or at time of next scheduled appointment. All cash pay prices are subject to change to regular office visit prices if not paid at time of service. By signing below you are confirming that the information you have provided is correct and true to the best of your knowledge. I hereby acknowledge that I have received a copy of Mountain Medicals Notice of Privacy Practices. I authorize the release of any medical information and payment of medical benefits to the undersigned physician or supplier for services necessary to process a claim. I agree to be responsible for any deductible, co-insurance, co-pay or any other balance not paid by insurance or settlement. Patient Name: Date: Signature: Relation to Patient:
INJURY INFORMATION: Address the Accident Occurred? City: State: Zip Code: Number of People Involved in the Injury: Date and Time Injury Occurred: INJURIES & TREATMENT: Where were you taken after the accident? When? Other Treatment or Studies List your symptoms in order of most too least severe: 1. 2. 3. 4. 5. 6. 7. 8. Patient Name: Date: Signature: Relation to Patient: