I request that payment of authorized Medicare benefits, or any other insurance benefits be made to either me or on my behalf to Centra Internal Medicine for any services furnished to me by the Physician/Provider. I authorize any holder of medical information concerning me to be released to my insurance carrier or health care financing. its agents, any information needed to determine these benefits or the benefits payable for related services. A photocopy of this authorization shall be considered effective and valid as the original.

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES NOT COVERED BY MY INSURANCE COMPANY.

To our patients: This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your Health Information.

The Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Our commitment to your privacy

We realize that these laws are complicated, but we must provide you with the following Important information.

Our practice is dedicated to maintaining the privacy if your Health Information. We are required by law to maintain confidentiality of your health information. 

Use and disclosure of your health information in certain special circumstances

The following circumstances may require us to use or disclose your health information:

To public health authorities and health oversight agencies that are authorized by law to collect information.

Lawsuits and similar proceedings in response to a court or administrative order.

If required by a law enforcement official.

When necessary to reduce or prevent serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organizations able to help prevent the threat.

If you are a member of U.S or foreign military forces (including veterans) and if required by the appropriate authorities.

To correctional institutions or law enforcement officials if you are an inmate or under custody of a law enforcement official.

Your rights regarding your health information.

Communication. You can request that our practice communicates with you about your health and related issues in a manner or at a certain location. For instance, you may ask if we contact you at home, rather than work. We will accommodate reasonable requests.

You can request a restriction of disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health Information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

You have the right to Inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing.

You may ask to amend your health information if you believe it is incorrect or incomplete, and if the information is kept by or for our practice. To request an amendment, your request must be made in writing.

Right to copy this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact our front desk receptionist.

Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact our Administrator. Al l complaints must be submitted in writing. You will not be penalized for filing a complaint.

Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

I hereby acknowledge that I have been presented with a copy of Notice of Privacy. 

At Centra Internal Medicine we believe in delivering exceptional patient care. However, our professional services are rendered to you, not your insurance company; therefore, payment for treatment is your responsibility. We are committed to navigating with you to get you your best allowed coverage.

Please notify us of any change in your insurance, address, place of employment, phone number, etc. when you arrive and before you see your physician or have any testing. Fai lure to notify us of these changes will result in you being responsible for the bill.

You may use Cash, Master Card, Visa, or Discover to charge current services or any outstanding balance on your account.

Payment Responsibility: The patient or his/her legal representative is ultimately responsible for all charges incurred. We do not have a contract with your insurance company. It is your responsibility to know and understand your insurance. We will do the best job we can to help you understand or direct you to the information, however we are not responsible for verifying that your insurance is an "in-network" participant.

Self-Pay Patients: For patients that do not have insurance, payment in full is due at the time of service. We offer a discount for all self-pay patients who pay at the time of service.

Co-Pays/Patient Balance: Your balance and co-pay is due at time of service. You may be asked to reschedule your appointment if you are not prepared to pay your co-pay.

Physicals: We recommend that you have a physical once a year, but it is your responsibility to clarify with your insurance if these services are covered with your health plan.

Non-covered Services: Payment for all charges which are not covered by insurance is due and payable at the time of service

Prior Unpaid Accounts: Prior to providing services, payment of prior outstanding account balance may be requested, or specific payment arrangements be approved by the Practice Administrator.

Collection Agency: Accounts which cannot be collected by Centra Internal Medicine after normal in-house collection procedures may be referred to a collection agency, for further collection action. Any fees incurred will be patient 's responsibility. If your account has been sent to collection, we will not be able to see you in the office until your balance is paid in full.

Forms: There will be a $10.00 fee due at the time of request associated with simple/one-page forms that need to be completed by the physician or office staff. For longer/complex forms, the fee charged will be $25 and will be due at the time of request. Allow 5-7 business days for the forms to be completed. All forms will be filled at the discretion of the provider

Lab Orders: It is your responsibility to check with your insurance company to confirm the coverage for your lab work. Physicians will order lab work but will not guarantee that your insurance company will cover it.

Auto Insurance: We will bill your attorney for auto-accident or other liability or lawsuit related case. You are responsible for payment if you do not have any of the above stated coverage. We will need all information associated with the claim to bill your carrier.

Worker's Compensation: If your injury is work related, we will need the case number and carrier name prior to your visits to bill the worker's compensation insurance company.

All insurance co-pays are due at the time of service

NO/Show /Late Cancellation Policy $25.00 fee for each no show or late cancellation, for cancellations less than 24 HRS before schedule time.

Patient Acknowledgement: I have read, understand, and agree with the above financial policy.

I consent to the release of protected health information that is required to carry out treatment, or for payment of healthcare operations on my behalf.

I have received a copy of the Notice of Privacy practices and am aware of the following:

• I have the right to place restrictions on the way my PHI is used or disclosed.

• I understand that once Centra Internal Medicine agrees to my restrictions; it must comply with these restrictions.

• I have a right to revoke my consent for use and disclosure of my PHI at any time. I understand that, if I chose to revoke my consent, I must submit a written statement that is signed by me.

• I understand that Centra Internal Medicine must immediately comply with my request to revoke consent, except to the extent that it has already taken some action based on my original consent.

• Centra Internal Medicine has reserved the right to change from time to time our privacy practices that are described in the Notice of Privacy Practices. Whenever we change our practices, we will modify the notice; accordingly, and we will inform you, placing the amendment date at the bottom of the posted notice.

I understand that on occasion Centra Internal Medicine may need to contact me concerning health matters. On these occasions, I give permission to speak to another authorized party.

Name of Authorized Entity or Person(s) to receive information:

If you have done of the following, please put the date if known. If not, leave blank

Please list anything that you are allergic to (Medications, Food, Insect Stings, ETC.) and your reaction.

(If you have no known allergies, please note N/A next to no known allergies)

Allergies and reactions (Please list reactions)

Centra Internal Medicine

Manish Sahni, MD

Heather Mednansky, NP Lora Lane, NP Melissa Scott, NP Pamela Fazekas, NP

13000 N 103^rd AVE.STE 60, Sun City, AZ 85351

Phone: (623) 594-4126 | Fax: (623) 594-4127

Our medical practice has adopted an electronic medical record system to improve the quality of our services. This system also allows us to collect and review your “medication history.” A medication history is a list of prescription medicines that we or other doctors have recently prescribed for you. This list is collected from a variety of sources, including your pharmacy and your health insurer.

An accurate medication history is very important to helping us treat you properly and in avoiding potentially dangerous drug interactions.

By signing this consent form, you give us permission to collect, and give us your pharmacy and your health plan permission to disclose, information about your prescriptions that have been filled in at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health conditions, such as depression. This information will become part of your medical record.

This medication history is a useful guide, but it may not be completely accurate. Some pharmacies do not make drug history available to us, and the drug history from your health plan might not include drugs that you purchased without using your health insurance. Yours Medication history might not include over the counter medicines, supplements or herbal remedies. It is still very important for us to take the time to discuss everything you are taking, and for you to point out to us any errors in your medication history.

I give permission to you to obtain my medication history from my pharmacy, my health plans and my other healthcare providers. 

Centra Internal Medicine

Manish Sahni, MD

Heather Mednansky, NP Lora Lane, NP Melissa Scott, NP Pamela Fazekas, NP

13000 N 103rd AVE.STE 60, Sun City, AZ 85351

Phone: (623) 594-4126 | Fax: (623) 594-4127

I hereby authorize the following facilities: Please provide Name of facility PHONE, NUM, FAX NUM

To release a copy of the following information:

Medical records may include confidential information related to HIV, Communicable diseases, Alcohol abuse, and mental health diagnosis and treatment.

1. I may revoke this authorization except to the extent that it has already been acted upon.

2. Treatment may not be condition on my providing this authorization unless the provision of healthcare is solely for the purpose of creating protected health information for disclosure to a third party.

3. Once this information is released, it may be re-disclosed by the recipient and may no longer be protected information.

4. I may have a signed copy of this authorization.