Acknowledgement – Receipt of Patient Rights and Responsibilities

By my signature on page 3, I acknowledge receipt of the Patient Rights and Responsibilities and have been given the opportunity to read it. I understand that this information is available to me upon my request.

Acknowledgement – Notice of Privacy Practices Receipt

By my signature on page 3, I acknowledge receipt of CSC’s Notice of Privacy Practices (HIPPA) and have been given the opportunity to read it I understand that this information is available to me upon my request.

Appointment Policy- Please call us at 505-932-7475 by 2:00 pm at least two days prior to your scheduled appointment to notify us of any changes or cancellations. To cancel a Monday a appointment, please call our office by 2:00pm on Friday. If prior notification is not given you will be charged at $50.00 cancellation fee for the missed appointment.

Payment Policy:

CSC is committed to providing you with the highest quality care. Please review our Payment Policy, should you have questions we will discuss prior to your exam. Insurance. We participate with plans, most insurance plans including Medicare. If you are not insured by a plan we are contracted with, payment in full is due at the time your exam is performed. I you are insured by a plan we are contracted with, but do not have your insurance information, payment in full is due at the time your exam is performed. Once we obtain your insurance information, we will bill the insurance company and refund your payment after the claim has been paid in full.

Co-Payments, Deductibles, & Co-Insurance: All co-payments, deductibles and co-insurance must be paid at the time your exams are performed per your contact with your insurance company.

Non-Covered Services: In some instances, the services you receive may not be covered or not considered medically necessary by Medicare or other insurance companies. In these instances, you will be required to pay for these services in full at the time of your exam.

Proof of Insurance: We require that we obtain a copy of your driver’s license and valid insurance card to provide proof of insurance. If we are not provided with the correct information, you will be held responsible for the balance of the claim.

Claims Submission: We will submit your claims and assist you in any way we reasonably can to help get the claim paid.

Coverage Changes: If your insurance changes, notify us immediately to avoid problems with your claim being paid. By my signature below, I acknowledge CSC’s payment Policy. I hereby assign all insurance benefits to CSC for services performed.

Non-insured patients: I agree that I am responsible for payment at the time of service unless prior arrangements have been made.

Referral & Insurance Card Responsibility: I understand that during the check in -process, if I don’t have my insurance card, I will be responsible for any payment rendered at the time of service.

Deductible/ Coinsurance: I assume and agree to pay all applicable deductibles and co-pays. If my deductible is not met, full payment will be collected at time of service. If my deductible has been met, my coinsurance amount may be collected at the time of service.

Non-covered procedures: I agree to pay for all non-covered services (preventative or routine) non covered by my insurance.

Collections: Once an account is placed in collection status, all future service. I understand that there will be a $25.00 fee for any returned checks. Patient/Guarantor agrees to pay all cost of collection, including attorney fees, collection fees, and contingent fees to collection agencies which may be more than 35% of the delinquent balance, such contingent fee to be added by the provider and collected by the collection agency immediately upon our referral of your account the collection agency of our choice.

Acknowledgement – Medical Record Request – By my signature below, I hereby authorize CSC to obtain and/ Or disclose my medical records for medical treatment purposes only to my physician (s), clinic, hospital, or to my insurance company without further written permission for continuation of care. Medical records request up to 10 pages will be provided at no charge to the patient, request(s) larger than 10 pages may incur a fee.

General Consent and Right to Refuse Treatment

General Consent to Treatment: By my signature below, I (or my authorized representative on my behalf) authorize CSC and their staff to conduct any diagnostic examinations, tests, and procedures and to provide any medications, treatments to effectively assess and maintain my health, and to assess, diagnose, and treatment my illness or injuries. I understand that it is the responsibility of my individual treatment healthcare provider(s) to explain to me the reason(s) for any particular diagnostic examination, test or procedure, the available treatment options and the common risks and benefits associated with these options as well as alternative courses of treatment.

Right to Refuse Treatment: In giving my general consent to treatment, I understand that I retain the right to refuse any particular examination, test, procedure, treatment, or medication recommended or deemed medically necessary as prescribed by my physician. I also understand that the practice of medicine is not an exact science and that no guarantees have been made to me as the results of my evaluation and/or treatment. Unless otherwise revoked, this authorization will expire in 1 year for the date of signature.

Advance Directives: You have the right to information CSC’s policy regarding Advance Directives. Advance Directives will not be honoured within the canter. In the event of life-threatening event, emergency medical procedures will be implemented. Patients will be stabilized and transferred to a hospital where the decision to continue or terminate emergency measures can be made by the physician and family. If the patient or patient’s representative wants their Advance Directives to be honoured, the patient will be offered care at another facility that will comply with their wishes. A prehospital medical care directive is a document signed by you and your doctor that informs emergency medical technicians (EMT)s or hospital emergency personnel not to resuscitate you. Sometimes this is called a DNR – Do Not Resuscitate. If you have this form, EMT’s and other emergency personnel will not use equipment, drugs, or devices to restart your heart or breathing, but they will not withhold medical interventions that are necessary to provide comfort care or to alleviate pain. IMPORTANT: Under New Mexico Law a Medical Orders Scope of treatment form (MOST) must be on letter head sized paper of Wausau Astrobright Terra Green 65lb cardstock to be valid. If you have any questions, please talk to your physician or anaesthesiologist.

I consent to treatment at Comprehensive Surgical Care as an outpatient depending on my medical needs. Treatment can include testing (for example, x-rays and pre-operative test), routine care and procedures (for example, intravenous fluids or injections), and evaluation (for example, interviews and physical exam). However, this general consent doesn’t include consent for invasive procedures (for example, surgery) or consent for my participation in research. Both these circumstances require a separate consent process.

I understand that I retain no property rights to any tissue samples or bodily fluids removed from my body (specimens) as part of treatment. I further understand that Comprehensive Surgical Care has no obligation to preserve these specimens, that it will retain or dispose of specimens according to its usual procedures.

I understand that I have the right to ask any questions about a proposed treatment (including the identity of any person providing or observing treatment) any time. Because medicine is not an exact science and the outcomes of treatment are dependent upon my medical condition, I understand that no guarantees can be made as to the outcome of my care.

Assignment of Benefits: I agree to assign any right I may have to receive payment from a health insurance plan or other payor9S) for services rendered by Comprehensive Surgical Care and the physicians caring for me during my treatment. I understand that I am financially responsible for all balances that are not covered by my health insurance plan or payor, as appropriate, based on the terms of contracts or the law. For example, the payment of non-covered services, deductibles and co-payments are considered to be the patient’s responsibility. I also understand that I am financially responsible for collection costs should my account become delinquent.

Notice Regarding Release of Health Information: Under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) and as further explained in Comprehensive Surgical Care Notice of Privacy Practices, Comprehensive Surgical Care may use and disclose medical information to physicians or other providers for the purposes of providing treatment, and to payors for the purpose of payment for medical treatment. I acknowledge the receipt of a copy of practices.

Personal Valuables:

I understand that Comprehensive Surgical Care is not responsible for lost personal belongings and valuables and that family members or friends should be asked to take home money, jewellery and clothing or I should request that these times be placed in a safe place (locker). I also understand that I should inform the staff if I have dentures, eyeglasses, contact lenses, prosthetics, or other items that I need to retain close by for personal functioning and to assure safekeeping.