Acknowledgement and Consents Financial Agreement and Assignment of Benefits I authorize Pacific Medical Group to release information acquired in the course of medical services to my insurance company to file and expedite payment. I authorize payment of benefits directly to the clinic. I agree to be financially responsible for the balance left after processing by my insurance and for non-covered services. All non-covered or partially covered charges are due in 30 days from the date of service. If I am unable to pay in full, I understand that a payment plan may be established. I acknowledge I have received a copy of Pacific Medical Group’s Credit and Payment Policy. Notice of Uses and Disclosures of Protected Health Information I understand that Pacific Medical Group will use and disclose health information about me. I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. I understand and agree that Pacific Medical Group may use or disclose my protected health information to: • Make decisions about and plan for my care and treatment; • Refer to, consult with, coordinate and manage my care and treatment with other health care providers; • Determine my eligibility for insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; • Perform various office, administrative and business functions that support my provider’s efforts to provide me with quality, cost-effective health care. I understand that I have the right to receive and review a written description of how Pacific Medical Group will handle information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the providers and staff of Pacific Medical Group, and my rights regarding my health information. I understand Pacific Medical Group reserves the right to change the Notice of Privacy Practices, and that I am entitled to receive a copy of the revised Notice of Privacy Practices. Pacific Medical Group will post any revised Notice of Privacy Practices in its office and on their website at: http://www.pacificmedicalgroup.com. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that Pacific Medical Group is not required by law to agree to such requests. o By signing below, I acknowledge that I have received a copy of Pacific Medical Group’s Notice of Privacy Practices. o By signing below, I acknowledge that I was offered a copy of Pacific Medical Group’s Notice of Privacy Practices and I have declined to take a copy at this time. 8.26.2015 Patient Name Date of Birth Patient or Legal Guardian Signature Date Patient or Legal Representative Signature Date Description of Representative’s Authority:
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Acknowledgement and Consents...4510 SW Hall Blvd 1185 S Elm St 6445 N Greeley Ave 1001.Molalla Ave, Ste 100 13200 SW Pacific Hwy Beaverton, OR 97005 Canby, OR 97013 Portland, OR 97217
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PatientorLegalRepresentativeSignature Date DescriptionofRepresentative’sAuthority:
� Beaverton � Canby � North Portland � Oregon City � Tigard 4510 SW Hall Blvd. 1185 S Elm St. 6445 N Greeley Ave. 1001 Molalla Ave., Ste 100 13200 SW Pacific Hwy.
Type of Information to be Released � Specific Information Only Please � Chart Notes � Immunization Records � Other:
� Laboratory Results � Medications Records ___________________________________
� X-Ray Reports/Films � Physical Therapy
� Most Recent Visit* � Medical records from __________ to ___________* � Last 2 years only* Note: If checkbox is not selected, entire record will be copied/printed. THERE MAY BE FEES FOR PROVIDING COPIES.
*Records more than 25 pages must be mailed not faxed
Protected or Sensitive Information
If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use
and disclosure of the information may apply. I understand and agree that this information will be disclosed if I place my initials in the
applicable space next to the type of information.
______ HIV / AIDS information Initials
______ Mental health information Initials
______ Genetic testing information Initials
______ Drug / Alcohol diagnosis, treatment, or referral information Initials
I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer be
protected under federal law. However, I also understand that federal or state law may restrict redisclosure of HIV/AIDS
information, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment or referral
information. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain health care services or reimbursement for
services. The only circumstance when refusal to sign means I will not receive health care services is if the health care services are solely for the purpose of providing
health information to someone else, and the authorization is necessary to make that disclosure. My refusal to sign this authorization will not adversely affect my
enrollment in health plan or eligibility for health benefits unless the authorized information is necessary to determine if I am eligible to enroll in the health plan. I may
inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of.
I understand that I may revoke this authorization in writing at any time, except: to the extent that action has been taken in reliance upon this authorization. If I revoke
my authorization, the information described above may no longer be used or disclosed for the purposes described in this authorization. Unless revoked earlier, this
authorization will expire 24 months from the date of signing or on (insert applicable date or event) _______________________________________________________.
We are pleased that you have chosen Pacific Medical Group, P.C. as your Primary Health Care Provider. Our goal is to provide you with the highest
level of professional medical care possible, while keeping medical costs to a minimum. In an effort to provide quality medical services, we have
established the following credit and payment policies.
If you have insurance:
We submit claims on your behalf to your primary and secondary insurance carriers. If you have questions or concerns about your insurance
coverage, please call your carrier. Your insurance contract is between you and your carrier. Any remaining patient balance is due within 10 days of
the date you receive your statement.
Non-Covered Services: Payment in full is required at the time of treatment for services not covered by your insurance. Co-payments: Co-payments
are due at the time of service. If you are unable to pay, your appointment may be rescheduled.
Medicare:
Pacific Medical Group, PC accepts Medicare assignment. We will submit your claim directly to Medicare and will bill your secondary insurance
after Medicare has paid their portion. You are responsible for any allowed amount that is not paid by Medicare and/or your secondary insurance.
Any remaining patient balance is due within 10 days of the date you receive your statement.
Oregon Health Plan:
To receive treatment, you must currently be covered by the Oregon Health Plan and assigned to this clinic or to a Primary Care Provider at this
location. You must be assigned to a health plan this clinic participates with. Proof of coverage is required at each time of service.
Workers Compensation:
Please notify the registration desk at each appointment if your visit is due to an injury covered by Workers Compensation. To file a Workers
Compensation claim, you will need the name of your workers compensation insurance carrier, the date of your injury, the name and address of your
employer at the time of the injury, and the claim number (if available). If you have questions or concerns about your insurance coverage, please call
your carrier. We cannot accept responsibility for negotiating a disputed claim.
Motor Vehicle or Other Liability Claims:
Pacific Medical Group, P.C. requires payment within 30 days from the date of service, for visits related to motor vehicle/personal liability injury.
The patient is required to provide accurate complete billing information at the time of service when applicable.
Pacific Medical Group, P.C. requires a $50.00 deposit at the time of service for each visit regarding a motor vehicle accident or personal liability
injury.
In the event that your claim is disputed or a suit is established against another party, Pacific Medical Group, P.C. cannot accept the responsibility of
collecting on these cases or negotiating settlements. Patients will be asked to work with our business office to establish a suitable payment plan to
pay the balance of your medical charges. While we understand that settlement of these cases can take months, we do not feel that suit against another
party is reason for non-payment of your medical charges.
If you do not have insurance:
We require self-pay (uninsured) patients to pay a deposit at time of treatment. In circumstances where unexpected major medical expenses are
incurred, we will help you arrange a payment schedule.
Broken and Canceled Appointments:
Our clinic requests that you notify us 24 hours in advance when canceling a scheduled appointment. We reserve the right to charge a fee for any
appointment canceled or broken without reasonable notice.
Financial Responsibility:
Patients are financially responsible for all services rendered. If you are required to pay for treatment at the time of service, but are unable to do so,
your appointment may be rescheduled. A fee will be assessed for checks returned for insufficient funds. Failure to meet financial responsibility will
result in legal action.
Effective January 1, 2011, a rebilling charge of $5 will be added to all accounts with unpaid patient responsibility balances over 60 days.
Exceptions to these policies will not occur unless you make prior arrangements with our business office.
Agreement:
I have read and understand the Pacific Medical Group, P.C. Credit and Payment Policy. My signature below indicates that I accept this policy and
agree to abide by the terms for my treatment with Pacific Medical Group, PC.
PRINT PATIENT NAME Patient Signature or Legal Guardian, if patient is a minor Date
We accept: Cash, Personal Checks, Money Orders and Most Major Credit Cards Rev06.2011
rev2.2016
Genetic Privacy Notice
NOTICE OF YOUR RIGHT TO DECLINE PARTICIPATION IN FUTURE ANONYMOUS OR CODED GENETIC RESEARCH
Pacific Medical Group is required by Oregon law to provide this notice to you regarding use of your health information or biological samples for genetic research (OAR 333-025-0100 – 333-025-0165). State laws protect the genetic privacy of individuals and give you the right to decline to have your health information or biological samples used for research.
A biological sample may include a blood sample, urine sample, or other material collected from your body. You can decide whether to allow your health information or biological samples to be available for genetic research. Your decision will not affect either the care you receive from your health care provider, or your health insurance coverage.
Research is important because it gives us valuable information on how to improve health, such as ways to prevent or better treat heart disease, diabetes and cancer. Under Oregon law, a special team reviews all genetic research before it begins. This team makes sure that the benefits of the research are greater than any risks to participants. In anonymous research, personal information that could be used to identify you, such as your name, Social Security number or medical record number cannot be linked to your health information or biological sample. In coded research, personal information that could be used to identify you is kept separate from your health information or biological sample, making it very difficult to link your personal information to your health information or biological sample. Your identity is protected in both types of research. If you want to allow your health information and biological sample to be available for anonymous or coded genetic research, you don’t have to do anything . If you make this choice, your health information or biological sample may be used for anonymous or coded genetic research without further notice to you. If you do not want to have your health information and biological sample available for anonymous or coded genetic research, you must tell your health care provider by:
• Requesting and completing the Genetic Privacy Opt-Out form from the clinic front desk, and
• Giving or mailing the form to your health care provider. The Genetic Privacy Opt-Out form can be obtained from your health care provider at the clinic’s front desk. No matter what you decide now, you can always change your mind later by completing a form and returning it to your health care provider. Your new decision is effective on the date your health care provider receives the Genetic Privacy Opt-Out form, and will apply only to health information or biological samples collected after your health care provider receives the form. If you have questions about genetic research, please call the Oregon Genetics Program at 971-673-0271.
rev2.2016
Genetic Privacy Opt-Out
GENETIC PRIVACY – OPT OUT STATEMENT
□ I have read and understand the Genetic Privacy Notice and I DO NOT WANT to have my health information and/or biological samples available for anonymous or coded genetic research,
Patient’s Name (Print): _ _ Today’s Date:
Patient’s Signature: _ _ _ _ _
Patient’s Date of Birth: _ _ _ _ _
Personal Representative’s Name (Print): _ _
Personal Representative’s Signature: _ _ _ _
Describe authority and relationship to Patient: _ _ _
Regardless of your decision now, you may change your decision at any time by completing a new Genetic Privacy Notice form and returning it to your health care provider. Your new decision is effective on the date that your health care provider receives your new Genetic Privacy Notice and will apply only to health information or biological samples collected after your health care provider receives your new directive. If you have questions about genetic research, please call the Oregon Genetics Program at 971-673-0271.
This directive will be retained in your medical chart throughout your relationship with Pacific Medical Group.
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Typewritten Text
OTHER FAMILY MEDICAL HISTORY:______________________________________________________________________________________________________________________________________________________________________________
MEDICAL HISTORY
FAMILY HISTORY
Cancer:
Heart Attack:
Diabetes:
High Blood Pressure:
High Cholesterol
Kidney Disease:
Stroke:
Seizure Disorder:
Depression:
Alcoholism:
Bleeding Disorder:
Mental Health:
Other:
Alcohol Trouble
Anxiety
Asthma
Back Trouble
Bleeding Disorder
Cancer
Chicken Pox
Depression
Diabetes
Epilepsy
Fainting Spells
German Measles
Glaucoma
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
High Cholesterol
Kidney Trouble
Lung/Respiratory Disease
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
Lung Trouble
Measles
Memory Loss
Migraine
Mononucleosis
Mumps
Nervous Breakdown
Peptic Ulcer
Polio
Rheumatic Fever
Scarlet Fever
Sexual Diseases
Stomach Ulcer
Stroke
Thyroid Trouble
Tuberculosis (T.B.)
Urinary Tract Infection
Whooping Cough
Other Illnesses
If Yes, please describe:
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
Accidents/Fractures
If yes, please describe:
Appendectomy
Back
Breast
Cataract
Colon or Intestine
Ear Tube Replacement
Gallbladder
Hernia
Heart
Hysterectomy
Prostate
Tonsillectomy
Other Surgeries
If yes, please describe:
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
Tobacco
Alcohol
Drugs
Caffeine
Exercise
HABITS:yes
yes
yes
yes
yes
ALLERGIES: Describe
How much? SOCIAL HISTORY yesMarried yesSingle
CURRENT MEDICATIONS: (List by name, including over the counter)
PERSONAL HISTORYILLNESSES: Please fill in “yes” for all that you have been treated for. SURGERIES:
Date of Birth: Gender: M F Other Date:
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
Date of Previous Screening Tests:(If applicable)
PAP smear
Mammogram
Bone Density
Colonoscopy
Name:
pmg med hx 03/16
Widowed yes Divorced yes Partnered yes
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Immunization Dates: (If applicable)
Pneumococcal
Flu Tetanus
Ophthalmologist Visit :(If applicable)
Date:
Name:
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Non-CoveredEntityAuthorization Revised 4.2010
Authorization to Use/Disclose Protected Health Information **Release by Pacific Medical Group to a Third Party (Non-Covered Entity)**
------------------------------------------------------------------------------------------------------------------------------------------------------------------ THIS AUTHORIZATION MUST BE COMPLETED IN FULL FOR IT TO BE VALID.
Patient Name (Print) ___________________________________________________ DOB _____________________________ I authorize Pacific Medical Group to disclose my protected health information to: ______________________________________________________________________________________________________
Please Print (Name, phone # and address of recipients) for the purpose(s) of: ______________________________________________________________________________________________________
Please Print (Describe each purpose of the use/disclosure)
My protected health information includes medical records, emergency and urgent care records, billing statements, diagnostic imaging reports, transcribed hospital records, clinical office chart notes, laboratory reports, pathology reports, physical therapy records, hospital records (including nursing records and progress notes), and any personal or medical information related to the purpose of this Authorization. Information obtained with this Authorization will be used solely for the purpose defined above and will be limited to the minimum necessary information to achieve that purpose. If the information to be disclosed contains any of the types of records or information listed immediately below, additional laws relating to use and disclosure of the information may apply. I understand and agree that such information will be disclosed if I place my initials in the applicable space next to the type of information to be included with the disclosure: ______HIV/AIDS test or result information and related records
______Mental health information
______Genetic testing information
______Drug/alcohol diagnosis, treatment, or referral information
I have the right to revoke this authorization by sending a written statement to the Clinic Manager at Pacific Medical Group or other specified person at Pacific Medical Group ______________________and state that you are revoking this authorization. If you revoke your authorization, the information described above may not longer be used or disclosed for the purpose described in this written authorization. Any use or disclosure already made with your permission cannot be undone. I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and may not longer be protected under federal law. However, I also understand that federal or state law may restrict redisclosure of HIV/AIDS test or result information, mental health information, genetic information and drug/alcohol diagnosis, treatment or referral information. Unless revoked, this Authorization shall be in force and effective until the following (must give DATE or EVENT, check one):
at which time this Authorization to use or disclose this protected health information expires. Further, this Authorization is null and void 24 months from the date of signature.
I have reviewed and I understand this Authorization.