Disclosure, Consent, and Patient Privacy Agreement

(Pursuant to the Health Insurance Portability and Accountability Act of 1996, HIPAA)

By my signature below, I acknowledge and agree to the following privacy, consent, and disclosure practices.

Verification of Medical Consent: I hereby agree and consent to the plan of care proposed to me by Oak Lawn Immediate Care. I understand that I, or my authorized representative, have the right to decide whether to accept or refuse medical care. I will request any information I need about my medical care and make my wishes known. Oak Lawn Immediate Care shall not be liable for the acts or omissions of independent contractors.

Authorization to Release Information: I understand and hereby authorize Oak Lawn Immediate Care and/or staff, to the extent required to assure payment, to disclose any diagnosis and pertinent medical information to a designated person, corporation, government agency, or third party payer which is liable for charges from my visit or who may be responsible for determining the necessary treatment charges. This includes medical services companies, insurance companies, workers’ compensation carriers, Social Security Administration, intermediaries, and the State Department of Health and Human Services, when the patient is a Medicare recipient. This consent shall expire upon the final payment of my care.

Private Pay Patients: I hereby agree, whether signed as an agent or as a patient, to be financially responsible to Oak Lawn Immediate Care for charges not paid by insurance. I understand that this amount is due upon billing.

Insurance Coverage: I certify that the information given to me in applying for payment under government or private insurance is correct. I hereby assign payment directly to Oak Lawn Immediate Care for benefits otherwise payable to me. Any portion of the charge not paid by insurance will be billed to me and is then due and payable within thirty days of invoice. I understand that Oak Lawn Immediate Care will verify my insurance coverage but that this does not guarantee payment by the insurance company and I will be responsible for all non-covered charges. I understand that it is my responsibility to determine the coverage limits of my insurance.

Authorization to Mail, Call, or Email: I certify that I understand the privacy risks of mail, phone calls, and email. I hereby authorize Oak Lawn Immediate Care representatives and/or staff to mail, call, or email me with communications regarding my healthcare, including but not limited to appointment reminders, referral agreements, and laboratory results. I understand that I have the right to decline this authorization at any time by notifying Oak Lawn Immediate Care.

Lab/X-Rays/Diagnostic Services: I understand that I may receive a separate bill if my medical care includes lab, x-ray, or any other diagnostic services. I further understand that I am financially responsible for any co-pay or balance due for these services if they are not reimbursed by my insurance company for whatever reason.

Consent to Treatment: I hereby consent to the evaluation, testing, and treatment as directed by Oak Lawn Immediate Care physician or his/her designee. I also give consent to any minor surgery that may occur if needed, as directed by Oak Lawn Immediate Care physician or his/her designee.