Subscriber Information (person held responsible for the bill):

Consent to Treatment, Medical Records Release and Insurance Appeals

I hereby request and consent to treatment for myself or my child at San Francisco Otolaryngology Medical Group.

I authorize the release of any medical records or other information necessary for the processing of medical claims on behalf of myself or my child.

I hereby consent for San Francisco Otolaryngology Medical Group to act on my behalf in pursuing any insurance appeals necessary to obtain payment for services rendered. I acknowledge that insurance appeal advocacy does not constitute legal representation, and that I may retain outside legal counsel to participate concurrently, if I so choose.

Financial Information

• Please be prepared to pay your co-payment and any outstanding balance at the time of your visit. You may be responsible for services defined by your insurance as denied or non-covered
• Please bring your current insurance I.D. card to every appointment. If we are unable to verify your insurance coverage or authorization, you may reschedule your appointment to a later date, or you may elect to keep your appointment that day. If you keep your appointment, you will be required to pay for the visit; we will make a reasonable attempt to bill your insurance and request a refund directly to you.
• If your insurance requires a referral from your primary care physician, please make sure that you have one that is valid for your visit and that it covers any necessary tests needed.
• We will be happy to bill your secondary insurance as a courtesy. If your insurance fails to pay within 30 days of the primary insurance payment, the balance will be forwarded to you.

Notice of Privacy Practices Acknowledgement

This is required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. It is available in print form at our front desk or electronic download on our website sfotomed.com.

By signing below, you acknowledge that:

• You have been provided with and understand that San Francisco Otolaryngology Notice of Privacy Practices provides a complete description of the uses and disclosures of your health information
• As part of your health care, San Francisco Otolaryngology Medical Group originates and maintains health records describing your health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment.
• San Francisco Otolaryngology reserves the right to change its Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address you have provided, if requested.
• You have the right to review San Francisco Otolaryngology Medical Group Notice of Privacy Practices prior to signing this acknowledgement

I have read and understood ALL the information on this page

FORM COMPLETED BY:

The above information is accurate to the best of my knowledge.