Patient Consent for Financial Communications

Financial Agreement.

I acknowledge that as a courtesy, Fast Doc LLC may bill my insurance company for services provided to me. I agree to pay for services that are not covered or covered charges not paid in full including, but not limited to any co-payment, co-insurance and/or deductible, or charges not covered by insurance. I understand there is a fee for returned checks.

Third Party Collection.

I acknowledge Fast Doc LLC may use the services of a third-party business associate or affiliated entity as an extended business office ('EBO Servicer') for medical account billing and servicing.

Assignment of Benefits.

I hereby assign to the practice any insurance or other third-party benefits available for health care services provided to me. I understand Fast Doc LLC has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to the practice, I agree to forward all health insurance or third party payments that I receive for services rendered to me immediately upon receipt.

Medicare Patient Certification and Assignment of Benefit.

I certify that any information I provide, if any, in applying for payment under Title XVIII ('Medicare') or Title XIX ('Medicaid') of the Social Security Act is correct. I request payment of authorized benefits to be made on my behalf to Fast Doc LLC by the Medicare or Medicaid program.

Consent to Telephone Calls for Financial Communications.

I agree that, in order for the practice, or Extended Business Office (EBO) Servicers and collection agents, to service my account or to collect any amounts I may owe, I expressly agree and consent that the practice or EBO Servicer and collection agents may contact me by telephone at any telephone number, without limitation of wireless, I have provided or the practice or EBO Servicer and collection agents have obtained or, at any phone number forwarded or transferred from that number, regarding the services rendered, or my related financial obligations. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

Release of Information.

I hereby permit Fast Doc LLC and the physicians or other health professionals involved in the patient care to release healthcare information for purposes of treatment, payment, or healthcare operations.

Healthcare information regarding a prior service(s) at other Fast Doc LLC affiliated providers may be made available to subsequent Fast Doc LLC affiliated providers to coordinate care. Healthcare information may be released to any person or entity liable for payment on the Patient's behalf in order to verify coverage or payment questions, or for any other purpose related to benefit payment. Healthcare information may also be released to my employer's designee when the services delivered are related to a claim under worker's compensation.

If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. This information may include, without limitation, history and physical, emergency records, laboratory reports, operative reports, physician progress notes, nurse's notes, consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary.

Federal and state laws may permit this healthcare provider to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIDS

I, hereby consent to the above, to receive medical evaluation, diagnosis, and treatment provided by the healthcare providers at Fast Doc LLC. I understand that medical care may include diagnostic procedures, laboratory tests, or other services deemed necessary by my healthcare provider.