Consent to Bill Insurance

I understand this visit is NOT a free consultation or screening. I acknowledge this visit will be billed to my insurance. I also understand depending on my particular insurance benefits I may have copays (which includes separate copays for ultrasounds), deductible, and out of pocket expenses that I will be responsible to pay once these claims process with my insurance company.

DELINQUENT ACCOUNTS: We review past due accounts frequently and at every statement cycle. Your communication and involvement to ensure your balance is paid timely is important to us. It is imperative that you maintain communications and fulfill your financial agreement and arrangements to keep your account active and in good standing. If your account becomes sixty (60) days past due, further steps to collect this debt may be taken. If you fail to pay on time and we refer your account(s) to a third party for collection, a collection fee will be assessed and will be due at the time of the referral to the third party. The fee will be calculated at the maximum percentage permitted by applicable law, not to exceed 18 percent. In addition, we reserve the right to deny future non-emergency treatment for any and all debtor-related unpaid account balances.

CONSENT TO CONTACT: I grant permission and consent to AdvancedHEALTH and its agents, assignees, and contractors (which may include third party debt collectors for past due obligations): (1) to contact me by phone at any number associated with me, if provided by me or another person on my behalf: (2) to leave messages for me and include in any such messages amounts owed by me: (3) to send me text messages or emails using any email address I provided or any phone number associated with me, if provided by me or another person on my behalf: and (4) to use prerecorded/artificial voice messages and/or an automated telephone dialing system (an auto dialer) as defined by the
Telephone Consumer Protection Act in connection with any communications made to me as provided herein or any related scheduled services and my account. I understand that my refusal to provide the consent described in this paragraph will not affect, directly or indirectly, my right to receive healthcare services.

Patient Consent for Medical Photography

I, the undersigned, do hereby authorize Siragusa Vein & Laser’s employees to take photographs or video of me while I am under their care. I agree that they may use or permit other persons to use the electronic or print versions of my images for (check any or all that apply)

Notice of Privacy Practices Acknowledgement

I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy
regarding my protected health information (PHI). 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 received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and
disclosures of my PHI. 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 any time to obtain a current copy of the Notice of Privacy Practices.

General Consent for Treatment / Advanced Health

As the patient, you have the right to be informed about your conditions and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify appropriate treatment and/or procedure for any identified condition(s).

I request and authorize medical care as my provider, his assistant or designees (collectively called “the providers”) may deem
necessary or advisable. This care may include, but is not limited to, routine diagnostics, radiology and laboratory procedures, administration of routine drugs, biological and other therapeutics, and routine medical and nursing care. I authorize my provider(s) to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I understand that my (the patient) care is directed by my provider(s) and that other personnel
render care and services to me (the patient) according to the provider(s) instructions.

I understand that I have the right and the opportunity to discuss alternative plans of treatment with my provider and to ask and have answered to my satisfaction any questions or concerns.

In the event that a healthcare worker is exposed to my blood or bodily fluid in a way which may transmit HIV (human immunodeficiency virus), hepatitis B virus or hepatitis C, I consent to the testing of my blood and/or bodily fluids for these infections and the reporting of my test results to the healthcare worker who has been exposed.

I HAVE READ OR HAD READ TO ME AND FULLY UNDERSTAND THIS CONSENT; I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND HAD THESE QUESTIONS ADDRESSED.

Release of Medical Information

By Signing Below, I Authorize AdvancedHEALTH to Release My Medical and Billing Information To:

AdvancedHEALTH may leave appointment information on my voicemail:

I authorize the following to pick up prescriptions, X-rays, etc.

I understand that AdvancedHEALTH will ask for identification of the person picking up patient medical information or products.

Patient Financial Policy

This is an agreement between AdvancedHEALTH, as creditor, and the Patient/Debtor named on this form and indicated by patient/debtor signature below. In this agreement the words “you”, “your” and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we”, “us” and “our” refer to AdvancedHEALTH. By executing this agreement, you are agreeing to pay for all services that are rendered.

Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement
will be in full force and effect. A copy of your signed financial agreement will be provided to you.

HEALTH INSURANCE - It is YOUR responsibility to: •Ensure we have been provided with the most current insurance information relative to filing your claim including insurance card, ID number, employer, birth date and patient address. This information will be located on our patient registration form. • Ensure we are contracted with your insurance carrier to receive maximum benefits. • Pay your co-payment or patient portion at the time of service. • Inform us of any insurance changes made after this signed agreement/date of service. Insurance carriers have specific timely filing guidelines and pre-authorization requirements for certain services. If revised insurance information is not provided to us within your insurances’ timely filing limits, you will be required to pay for services in full. If prior authorization was required for services already received and your claim is denied for lack of authorization, you will be required to pay for services in full. • Contact your insurance company if no correspondence is received by you within 45 days of the date of service. It is OUR responsibility to: • Submit a claim to your health insurance carrier based on the information provided by the patient/debtor at the time of service or as updated information is provided. • Provide your health insurance carrier with information necessary to determine benefits. This may include medical records and/or a copy of your insurance card. • Provide MVA patients a courtesy health insurance claim form for their records upon request. PAYMENT OPTIONS: Per our contracted agreement with your insurance carrier, we are required to collect your co-payment on the day of service. If you do not have insurance, you are required to pay for treatment at the time of service unless other arrangements have been formally made. A separate self-pay financial agreement will be provided to you. Our office collects all copays plus estimated coinsurance and deductibles at the time of service. We accept the following: Cash, Check, Credit Card (Visa, MasterCard, Discover, American Express, Care Credit) A twenty-five dollar ($25.00) returned check fee will be assessed to the patient account per incident. For convenience, payments may be made online at www.ePayItOnline.com. To use this service, you will need your account number, access code, and Code ID. This information can be found on the patient statement you will receive reflecting your balance. Patients who no-show may be subject to a no-show fee. PENDING APPROVALS FOR SERVICES: In the event we are unable to obtain approval for services and you wish to proceed, we will not bill your insurance. Services will be reduced to the in-network insurance allowable amount and will apply to the patient’s responsibility.

Cancellation/No-Show Policy

At Siragusa Vein and Laser, we schedule our appointments so that each patient receives the right amount of time and attention with our physicians and other clinicians. We have a long wait list of patients, and missed appointments keep us from treating those who need our care. As a courtesy, and to help patients remember their scheduled appointments, we send reminders in advance of your appointment times. If your schedule changes, and you cannot keep your appointment, please contact us prior to 24 hours before your appointment , so we may reschedule you, and accommodate those patients who are having leg pain and waiting for an appointment. All missed appointments and cancellations made within 24 hours of your scheduled appointment will result in a cancellation fee:  Cancellation Fee - $100 If you are unable to attend your scheduled appointment time for any reason, please call us at 615-884-7600 and inform our team as soon as possible. My signature confirms that I have read and understand the Cancellation/No-Show Policy for Siragusa Vein and Laser. My signature also authorizes Siragusa Vein and Laser to charge my account accordingly for any missed appointments or cancellations with less than 24 hours notice.

MOTOR VEHICLE ACCIDENTS (MVA’s)

Unless prior agreement has been reached or I am a Medicare recipient, my health insurance will be filed for services related to this accident. In the event I do not provide insurance information upon initial visit, I understand insurance denials may occur depending on type of service(s) received or carrier specific filing requirements. I agree, as the patient or patient’s guardian, I am ultimately responsible for all balance(s) due to this facility and/or its physician(s) for services rendered regardless of insurance denial(s) or unfavorable case outcomes. If I have chosen an attorney to oversee my case, this financial agreement will serve as a Letter of Protection to my attorney. I further understand my account may be handled by an outside entity that specializes in attorney lien accounts at the facilities discretion.

WORKERS’ COMPENSATION INJURIES:

Written approval/authorization by your employer and/or workers’ compensation carrier prior to your initial visit is needed. We will contact your case manager and/or supervisor to confirm your workers’ compensation injury. If this claim is denied, for any reason by your employer or your employer’s workers’ compensation carrier, you will be responsible for payment in full. If denial is made by workers’ compensation, health insurance can be filed for these denied services and you will be held responsible for the account.

BILLING INFORMATION
STATEMENTS:

A statement of account will be provided to you if insurance has paid leaving a patient portion, denied or no response is received. Due to the
type of service we provide, you may receive billing from more than one practice, otherwise known as split billing. The balance on your
statement is due and payable within 30 days of receipt unless other arrangements are made with our billing department. The statement
will be sent to the address provided at the time of service. In the event your mailing address changes after your service date and your
account has not been paid in full, you are required to notify our billing office of this change by calling 615.851.6033 ext. 2067. In case of
divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a
divorce or separation, the parent authorizing treatment for a child at time of service will be the parent responsible for those subsequent
charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, court documentation is required for any
guarantor address changes, otherwise, it is the authorizing/custodial parent’s responsibility to collect from the other parent. Any account
with a credit balance of less than <$5.00> will not be refunded without specific request from the patient/debtor.
DELINQUENT ACCOUNTS:
We review past due accounts frequently and at every statement cycle. Your communication and involvement to ensure your balance is paid
timely is important to us. It is imperative that you maintain communications and fulfill your financial agreement and arrangements to keep
your account active and in good standing.
If your account becomes sixty (60) days past due, further steps to collect this debt may be taken. If we must refer your account to a
collection agency, you agree to pay all the collection costs, which are incurred. If we must refer collection of the balance to a lawyer, you
agree to pay all lawyer fees which we incur plus all court costs. In case of suit, you agree the venue shall be Davidson County, Tennessee. In
addition, we reserve the right to deny future non emergency treatment for any and all debtor-related unpaid account balances.
WAIVER OF CONFIDENTIALITY:
You understand if your account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is
reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.
MEDICAL RECORDS:
You will be required to request in writing or sign a medical authorization form for the release of your medical records to any organization or
physician. We charge a $20 flat rate for 1-5 pages plus .50 per additional page and postage.