I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. My health information will not be disclosed to anyone unless I direct you to do so, unless the law authorizes you. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow up among the multiple healthcare providers who may be involved in the treatment directly and indirectly

Obtain payment from third-party payers

Conduct normal healthcare operations such as quality assessments and physician certifications

I understand that my personal medical information cannot be disclosed unless I have authorized it in writing and/or by signing a Release of Information form. This includes, but not limited to, immunization records, growth charts, progress notes, well child visits and medications and demographic information.

I understand that medical information will not be shared via e-mail, this includes immunization records.

I have been informed by you of your Notice of Privacy Practices continuing a more complete description of the users and disclosure of my health information. I have been given the right to review such Notice of Privacy prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used, disclosed to carry out treatment or payment of healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time except to the extent that you have taken action relying on this consent.

Thank you for choosing Evergreen Pediatrics as your healthcare provider. We are committed to providing the best medical care possible. Please understand that payment of your bill is considered a part of your treatment. The following statement explains our Financial Policy, which we ask you to read, sign and return to us prior to your treatment.

All patients should provide accurate and complete personal and insurance information prior to being seen by the doctor.

All applicable co-pays, personal balances, both current and prior, are due at the time of service or upon receipt of invoice.

We accept cash, check, or credit cards.

Regarding Insurance

We participate in most insurance plans; we require that the guarantor, the person who is financially responsible, is personally liable for all balances not covered by insurance. It is your responsibility to understand and comply with any Pre-determination of benefits or referral requirements. Please be aware that some, and perhaps all, of the services provided may be non-covered services or may not be considered medically necessary under the Medicaid program or by other medical insurance companies.

We will file all insurance claims with the insurance provider you supply our office with. Please be sure to update our office of any changes in your insurance. Please also remember that insurance is a contract between the patient and the insurance company and ultimately, the patient is responsible for payment in full. Your insurance company may need you to supply certain information directly in order to pay the claim.

If you are uncertain about your current insurance policy benefits, you should contact your plan to learn the details about your benefits, out-of-pocket expenses, and coverage limits.

Missed Appointments

We require a 24-hour notice of appointment cancellation. Appointments missed and are not previously cancelled may be charged a fee of $25.00.

Past Due Accounts

I/We agree to pay all attorneys’ fees, court costs, and filing fees, which may be assessed by any collection agency or law firm retained to pursue the matter.

Address Changes

It is our policy to provide invoices for any amounts owed on your account. We send all correspondence to the address information you provide, so please advise us anytime there is a change to your address, telephone number or other contact information.

Returned Checks

For checks returned to us as unpaid by your bank, we will charge a $25.00 fee.