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Consent to the Use and Disclosure of Health Information For Treatment, Payment, or Healthcare Operations

I understand that as part of my health and medical care, at Neurology Care originates and maintains medical and health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.

I further understand that this information serves as: a basis for planning my care and treatment, a means of communication among the health professionals who contribute to my care, a source of information for applying my diagnosis and treatment information to my bill, a means for a third-party payer to verify that services were billed as actually provided, a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I further understand and agree that this agreement to release information shall apply to all information accumulated up to this date and to any information acquired in the future. This agreement to release future information shall remain in force until such time as I shall revoke it in writing. By Oklahoma law we are required to notify you ... that the information authorized for release may include records which may indicate the presence of a communicable or venereal disease which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS)

Financial Responsibility

I hereby authorize payment of medical benefits directly to Neurology Care for services rendered. Authorization is hereby granted to release all information contained in my medical record to my medical insurance company (or its employees or agents) as may be necessary to process and complete my medical insurance claim. I understand that this authorization may include release of information regarding communicable diseases, such as Acquired Immune Deficiency Syndrome (“AIDS”) and Human Immunodeficiency Virus (“HIV”). I understand that I am financially responsible for the total charges for services rendered which may include services not covered by my insurance companies. I agree that all amounts are due upon request and are payable to Neurology Care. I further understand should my account become delinquent; I shall pay any expense incurred by Neurology Care in the collection of that account, if any. The duration of this authorization is indefinite and continues until revoked in writing. I understand that by not signing this release of information, I am responsible for payment of services in full before the services are rendered.

Notice for TCPA Prior Express Consent

You agree, in order for us to service your account, remind of appointments, or to collect any amounts you may owe, we or an outside agency (as necessary) may contact you by telephone at any number associated with your account, including wireless numbers, which could result in charges to you. We may also contact you by sending text messages or e-mails, using any phone number or e-mail address you provide to use. Methods of contact may include using prerecorded/artificial voice messages and/or use of an automatic dialing device, as applicable. We will be required to verify the account with information such as DOB, current address, last 4 numbers of social security number, etc.

Injection – Informed Consent

(If having any injections in the office) I hereby consent to and authorize the injection of therapeutic medication, such as OCNB, Trigger Point, ect., either intramuscularly (into the muscle) or subcutaneously (under the skin) by a licensed healthcare provider. I understand that the injection consists of introducing a needle into the muscle or under the skin and insertion of medication for the purpose of treatment for my condition. Preparation for the injection includes cleaning the skin with an antiseptic. This may cause some skin irritation. There exists the possibility of certain complications from this injection. These include pain, nerve damage, bleeding, swelling, allergic reaction to the medication, death or disability. I authorize a licensed healthcare provider to perform any emergency procedures that are in their professional judgement necessary to treat such problems if they occur. I acknowledge that the procedure and its potential risks outlined above have been explained to me.

We will be asking for a new copy of every patient’s insurance card(s) for the New Year.
All outside paperwork fees will be $25. (Paperwork: DMV paperwork, FMLA, ect.) We will not start the paperwork until the payment is received. We have 10 business days to complete all work.
For all injections that are not covered by insurance, a payment of $30 will be requested before the injection is given.
All co-pays/estimated co-insurances are due at the time of the visit. Note: All co-insurances are estimates of what you will owe from what is paid by your insurance, the price that is quoted to you is not definite as we are not responsible for what your insurance pays.
All Nursing Home Patients MUST be accompanied by a caregiver/family member capable of giving history or they cannot be seen.
All Self-Pay Patients are required to pay $175 for the initial consultation and $75 for each additional follow-up appointment, any testing will be additional. Payment is due on the day of the visit before being seen by the doctor.
All patients are required to bring a detailed (milligrams, dosage, frequency) list of current medications to each appointment.
We understand your time is important, as is ours, Patients are seen in order of appointment time, not arrival time.
We have daily booked appointments scheduled out in advance so, if you are 15 or more minutes late to your appointment, it will have to be rescheduled.
No show policy: After 3 no shows, we may require authorization from the office manager to reschedule.
Any patient who has been turned to collections will not be able to make an appointment until the balance is resolved.
If you need a prescription refill, please request it no later than 48 hours prior to running out of your medication.
Please note all prior authorizations could take up to a minimum of 3 days to be approved by your insurance company.
The nurse is in clinic with patients all day. Any prescription refills or messages will not be done until clinic is over. (Clinic is usually finished around 4:30pm and clinic is closed for lunch from 12:30-1:30)
All children are welcome in this clinic; however, if they become disruptive, we will ask you to reschedule your appointment for another day.

THIS AUTHORIZATION IS FOR RELEASE OF MEDICAL RECORDS INFORMATION. I UNDERSTAND THAT I CAN REVOKE THIS AUTHORIZATION AT ANYTIME PRIOR TO ACTION BEING TAKEN DUE TO THIS AUTHORIZATION FOR RELEASE. I UNDERSTAND THAT THE INFORMATION AUTHORIZED FOR RELEASE MAY INDICATE THE PRESENCE OF COMMUNICABLE OR VENEREAL DISEASE WHICH MAY INCLUDE, BUT IS NOT LIMITED TO DISEASES SUCH AS HEPATITIS, SYPHILIS, GONNORREHEA, OR THE HUMAN IMMUNODEFICIENCY VIRUS, ALSO KNOWN AS ACQUIRED IMMUNE DIFICIENCY SYNDROME (AIDS). (SEE 63 O.S. 1-502.2)

With this knowledge, I give my authorization to the release of all information in my medical record including any information concerning my identity, and release Neurology Care, affiliates, agencies, and employees from liability in connection with the release of the information contained therein.