HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights und r the law. You ascertain that by yqgt signature that you have reviewed our notice before signing this consent.

The tenns of the notice may change, if so, you will be notified at your next visit to update your signature/date,

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but ifwe do, we shall honor this agreement. The HJ.?AA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations,

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you, However, such a revocation will not be retroactive.

By signing this form1 I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and a11 full disclosures will then cease.
• The practice may condition receipt of treatment upon execution of this consent.

NEW PATIENT FORM

RESPONSIBLE PARTY/BILLING INFORMATION

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

PATIENT AUTHORIZATIONS

I authorize my insurance benefits to be paid directly to Sikora Integrative Medicine and I am financially responsible for all charges. I hereby consent to the release and re-disclosure of my medical record to enable or facilitate the collection, verification or settlement of my account for any amounts due from me or any third-party payor, health maintenance organization, insurer or other health benefit plan. This consent applies to Sikora Integrative Medicine or any of its affiliates or agents, lenders, or any third-party servicer.

I agree to promptly pay for services rendered for me or the patient named above. If I fail to meet my financial commitment to Sikora Integrative Medicine, and it becomes necessary to take action to collect my account, I agree to pay all costs and expenses incurred in the collection of my account, including attorney and collection agency fees. I further agree to pay for any missed appointments of which I did not notify the medical office within a reasonable amount of time.

I hereby understand that with treatment at Sikora Integrative Medicine I have given consent to testing and release of test results related to infection with human immunodeficiency virus or hepatitis B or C viruses, if in their opinion, an employee has suffered an exposure incident as a result of my treatment, as defined by the Centers for Disease Control and the Occupational Safety and Health Administration. I also understand I have consented to the release of such test results to the person who was exposed.

NO SHOW/CANCELLATION POLICY

Sikora Integrative Medicine requires at least 24 hours advanced notice for canceled appointments and/or procedures.

Any appointment or procedure that is not canceled with an advanced notice of 24 hours or you fail to show for your appointment you will be subject to the following cancellation fee of $50.00.

This fee is the responsibility of the patient and will not be billed to your insurance company.

Your signature below constitutes that you fully understand, acknowledge, and agree with the above policies set forth by Sikora Integrative Medicine.

RECEPT OF NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT

I have read and received a copy of Sikora Integrative Medicine’s NOTICE OF PATIENT PRIVACY PRACTICES policy.

SIKORA INTEGRATIVE MEDICINE GENERAL ACKNOWLEDGMENT AND WAIVER

BILLING POLICY

DEDUCTIBLES ARE DUE IN FULL AT THE TIME OF SERVICE.

Deductibles, co-payments and co-insurance amounts must be paid in full prior to seeing a physician and/or receiving medical care. Patients are responsible for verifying the amount of their deductible with their insurance company prior to their initial visit.

We accept cash, check, and major credit cards. Please note that a $25 service fee will be issued for any unpaid returned checks. Patient accepts responsibility for payment of this fee in addition to the original issued amount of the unpaid returned check.

The patient accepts full responsibility to provide current insurance plan information at the time of initial office visit. If this information is not provided or inaccurate, the patient accepts full responsibility for all charges billed during the visit.

We require re-verification of insurance card at each visit. It is the responsibility of the patient to provide Sikora Integrative Medicine with any changes or updates to the patient’s insurance plan. A service fee of $25 will be assessed if a patient’s bill is incorrectly submitted to an insurance company due to a lack of updated information. The patient accepts responsibility for this service fee and will be held responsible for all charges not covered by their insurance plan.

Accounts not paid within 90 days with a balance will be automatically turned over to a collection agency. The patient remains financially responsible and will be charged for the collection agency’s fee in addition to the past due amount.

Please note as of 1/1/2022 the self-pay follow up appointment has been increased to $125.

Patients are subject to a fee of $15 per page if additional paperwork/forms are required to be completed by our office staff. Disability forms may carry additional fees please inform the medical staff of such forms at the time of your arrival in order to estimate the fee prior to your visit.

All professional services rendered are charged to the patient who accepts responsibility for all charges regardless of the insurance carrier. Sikora Integrative Medicine will bill the patient’s primary and/or secondary insurance company on the patient’s behalf for Medicare, Blue Cross Options, and Cigna. Any remaining balance will be billed directly to the patient. We are not in network with other insurance plans at this time and will not directly bill other insurance plans. Any balance due, regardless of reason, is the patient’s responsibility to pay. Medicare and/or your private insurance carrier will only pay for services that determines to be “reasonable and customary” under Section 1862 (a) (1) of the Medicare law. It is the patient’s responsibility to verify that your insurance will cover any procedure that you are requesting to be done or that we provide. It is your responsibility to ensure that your insurance is active and to provide us with a copy of your current insurance card. If Medicare and/or my commercial insurance should deny any or all charges and/or I do not present with an active and/or current insurance card, I agree to be personally and fully responsible for any and all balances due.

NEW PATIENT QUESTIONNAIRE

Onset of Symptoms

Pain Intensity and Location

If pain “0” is no pain and “10” is the worst pain you can imagine, how would you rate your pain?

Pain Description

Mark all of the following tests that you have related to your current pain complaints:

Past Medical History (Please check all that apply)

Past Surgical History

Please list any surgical procedures you have had done in the past including date:

Current Medications

Please list all medications you are currently taking including vitamins. Attach additional sheet if required:

Allergies

If so, please list all medications you are allergic to:

Family History

Social History

Review of Systems

Mark the following symptoms that you currently suffer from:

Please fill out this agreement only if you are going to be prescribed opioid pain medications.

Pain Treatment with Opioid Medications: Patient Agreement

We will help you schedule regular appointments for medicine refills. If we have to cancel or change your appointment for any reason, we will make sure you have enough medication to last until your next appointment.

We will make sure that this treatment is as safe as possible. We will check regularly to make sure you are not having bad side effects.

We will keep track of your prescriptions and test for drug use regularly to help you feel like you are being monitored well.

We will help connect you with other forms of treatment to help you with your condition.

We will help set treatment goals and monitor your progress in achieving those goals.

We will work with any other doctors or providers you are seeing so that they can treat you safely and effectively.

If you become addicted to these medications, we will refer you for treatment to get off of the medications.

Addendum to Opioid Agreement (only for patients getting opioid/narcotic medications):

CONSENT TO TREATMENT AND/OR OPIOID DRUG THERAPY: I voluntarily request my physician to treat my condition which has been explained to me as chronic pain. I hereby authorize and give my voluntary consent for my physician to administer or write prescription(s) for dangerous and/or controlled drugs (medications) as an element in the treatment of my chronic pain.

It has been explained to me that these medication(s) include opioid/narcotic drug(s), which can be harmful if taken without medical supervision. I further understand that these medication(s) may lead to physical dependence and/or addiction and may, like other drugs used in the practice of medicine, produce adverse side effects or results. The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me as listed below. I understand that this listing is not complete, and that it only describes the most common side effects or reactions, and that death is also a possibility as a result from taking these medication(s).

THE SPECIFIC MEDICATION(S) THAT MY PHYSICIAN PLANS TO PRESCRIBE WILL BE DESCRIBED AND DOCUMENTED SEPARATE FROM THIS AGREEMENT. THIS INCLUDES THE USE OF MEDICATIONS FOR PURPOSES DIFFERENT THAN WHAT HAVE BEEN APPROVED BY THE DRUG COMPANY AND THE GOVERNMENT (THIS IS SOMETIMES REFERRED TO AS “OFF-LABEL” PRESCRIBING). MY DOCTOR WILL EXPLAIN THE TREATMENT PLAN FOR ME AND DOCUMENT IT IN MY MEDICAL CHART.

For female patients only:

To the best of my knowledge I am NOT pregnant.
If I am not pregnant, I will use appropriate contraception/birth control during my course of treatment. I accept that it is MY responsibility to inform my physician immediately if I become pregnant.
If I become pregnant or am uncertain, I WILL NOTIFY MY PHYSICIAN IMMEDIATELY.

All of the above possible effects of medication(s) have been fully explained to me and I understand that, at present, there have not been enough studies conducted on the long-term use of many medication(s) i.e. opioids/narcotics to assure complete safety to my unborn child(ren). With full knowledge of this, I consent to its use and hold my physician harmless for injuries to the embryo/ fetus / baby.

I UNDERSTAND THAT THE MOST COMMON SIDE EFFECTS THAT COULD OCCUR IN THE USE OF THE OPIOID DRUGS USED IN MY TREATMENT INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING: constipation, nausea, vomiting, excessive drowsiness, itching, urinary retention (inability to urinate), orthostatic hypotension(low blood pressure), arrhythmias(irregular heartbeat), insomnia, depression, impairment of reasoning and judgment, respiratory depression (slow or no breathing), impotence, tolerance to medication(s), physical and emotional dependence or even addiction, and death. I understand that it may be dangerous for me to operate an automobile or other machinery while using these medications and I may be impaired during all activities, including work.

The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me, and I still desire to receive medication(s) for the treatment of my chronic pain.

The goal of this treatment is to help me gain control of my chronic pain in order to live a more productive and active life. I realize that I may have a chronic illness and there is a limited chance for complete cure, but the goal of taking medication(s) on a regular basis is to reduce (but probably not eliminate) my pain so that I can enjoy an improved quality of life. I realize that the treatment for some will require prolonged or continuous use of medication(s), but an appropriate treatment goal may also mean the eventual withdrawal from the use of all medication(s). My treatment plan will be tailored specifically for me. I understand that I may withdraw from this treatment plan and discontinue the use of the medication(s) at any time and that I will notify my physician of any discontinued use. I further understand that I will be provided medical supervision if needed when discontinuing medication use.

I understand that no warranty or guarantee has been made to me as to the results of any drug therapy or cure of any condition. The long-term use of medications to treat chronic pain is controversial because of the uncertainty regarding the extent to which they provide long-term benefit. I have been given the opportunity to ask questions about my condition and treatment, risks of non-treatment and the drug therapy, medical treatment or diagnostic procedure(s) to be used to treat my condition, and the risks and hazards of such drug therapy, treatment and procedure(s), and I believe that I have sufficient information to give this informed consent.