RESPONSIBILITY, CONSENT & ASSIGNMENT OF BENEFITS

MEDICAL CONSENT: I, the undersigned, being the person whose name appears hereafter designated as the “patient” or being a person legally authorized to consent to services of, or on behalf of, the patient, do hereby voluntarily consent and authorize Suzanne Weakley, M.D. to administer any treatment which may be deemed necessary and advisable for the diagnosis and treatment of the patient, and to provide and perform such medical and surgical care, tests, procedures, drugs and other services and supplies as are considered advisable by my physician for my health and well-being. I understand that this may include, but not necessarily be limited to, pathology, radiology services, allergy and pulmonary function tests, and other special services and tests, including tests for communicable diseases. This consent and authorization extends to and includes, without limitation, staff physicians, resident physicians, interns, nurses, nurses aides, technicians, therapists, students and agents and employees of the office of Suzanne Weakley, M. D. providing services to said patient. I understand that the patient is under the care of the attending physician and that such physician is responsible to determine the nature and course of treatment for the patient. I further understand that under some circumstances, it might be impossible for the attending physician to give the necessary orders for treatment, and therefore, this consent and authorization extends to diagnosis and treatment of the patient by any of the persons or classes of persons above named, which is deemed necessary and advisable, whether ordered by the attending physician or not. I am aware that the practice of medicine is not an exact science and further state that no guarantee has been made to me as to the results that may be obtained from the treatments or procedures to be performed during the course of this treatment.

RELEASE OF INFORMATION: The undersigned agrees that to the extent necessary to determine responsibility for payment and to obtain reimbursement, the office of Suzanne Weakley, M.D. may disclose portions of the patient’s record, including their medical records, to any person or entity which is or may be responsible for all or any portion of Dr. Weakley’s charges, including but not limited to insurance companies, health care service plans, worker’s compensation carriers, medical or utilization review organization designated by any of the foregoing, or to any other person or entity as necessary in connection with such payment or reimbursement. I authorize any holder of medical or other information about me to release same and copies of any medical records to Dr. Weakley’s office, the Health Care Financing Administration, its agents or carriers, and my insurance carrier(s), necessary to determine benefits and/or to process claims for this and all related claims on my behalf, now or in the future. I request my insurance company(s) honor my assignment of insurance benefits applicable to the services and pay all assigned insurance benefits directly to my physician on my behalf.

PAYMENT GUARANTEE: In consideration of the services delivered by the office of Suzanne Weakley, M.D., the undersigned guarantees payment of the account, and agrees to pay the same at the time of visit if such account is not paid by a private or governmental insurance carrier, and to pay any balance due promptly upon receipt of my first statement. I agree to comply with the terms of my insurance coverage, including payment of co-pays at the time services are rendered. I understand that all accounts are the full responsibility of the patient and/or the patient’s responsible party. I understand that the office of Suzanne Weakley, M.D. may add a finance charge to any outstanding balance. If the amounts due the office of Suzanne Weakley, M.D. for services rendered become delinquent and the debt is referred to an attorney and/or third party for collection, it is understood and agreed that office of Suzanne Weakley, M.D. shall recover all costs and expenses incurred in the collection of any such delinquent amount.

ASSIGNMENT OF BENEFITS: In consideration of services to be rendered from time to time by the physician, I hereby authorize, request, and assign payment directly to the office of Suzanne Weakley, M.D. covering this period of treatment and future treatment, by all insurance carriers with whom I have coverage or from whom benefits are, or may become, payable to me, including settlements or judgments flowing from the incident for which I am receiving treatment. This assignment is a relinquishment and assignment of all legal or equitable interest which I have in any insurance benefits which exist by reason or contract or otherwise, including but not limited to, Major Medical and other special coverages, and including the right to sue or make claim for said benefits; this assignment is irrevocable except upon full payment of all indebtedness, or by express written agreement between the office of Suzanne Weakley, M.D., and the undersigned; this assignment does not constitute payment for indebtedness and does not relieve the undersigned from liability for unpaid indebtedness. In the event that insurance benefits to which I am entitled are paid directly to me for indebtedness incurred by me or a member of my family, or a person for whom I am financially responsible, I agree that I will immediately deliver all such benefit received.

PRIOR AUTHORIZATION: I understand that some insurance companies require prior authorization for certain procedures, and that maximum reimbursement and coverage may not be received if prior authorization is not obtained. I assume the responsibility of obtaining such authorization if necessary.

NOTICE: Your health insurance plan may require you to obtain some medical services from certain providers in order to be fully covered for those services under your plan. Please be sure to review your health care insurance plan before receiving any services at the office of Suzanne Weakley, M.D. In most cases, your insurance card will list a telephone number that you may call to obtain your health insurance benefit coverages and any restrictions on choosing a provider. Dr. Weakley offers a full range of the services you may need; however, in order to receive maximum insurance payment, you need to know your health insurance benefits coverage and which providers the insurance will fully pay.

THE UNDERSIGNED CERTIFIES THAT THEY HAVE READ AND UNDERSTAND THE FOREGOING AND EITHER IS THE PATIENT NAMED OR IS DULY AUTHORIZED BY THE PATIENT OR BY LAW TO ACCEPT THE TERMS ON THE PATIENT’S BEHALF.

INSURANCE AUTHORIZATION AND ASSIGNMENT OF BENEFITS:
I hereby authorize Dr. Weakley to furnish to my insurance carrier(s) information concerning my illness and treatment. I hereby assign to Suzanne Weakley, M.D. all benefits for medical services rendered to my dependents or myself. I understand that although I am covered by insurance, I am personally responsible for all charges. It is customary to pay for services when rendered unless other arrangements have been made IN ADVANCE with our office manager.

I understand that accounts over 90 days old with no payment activity may be turned over to a collection agency and it is my responsibility to keep in contact with this office regarding all outstanding balances. A service charge may be applied monthly on any unpaid balance.

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare Claim/other Insurance Company claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. (Section 1128B of the Social Security Act and 31 U.S.C. 3801-3812 provides penalties for withholding this information.)