Ruston 318-224-3044 • West Monroe 318-350-6644

Authorization and Consent

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Authorization and Consent 2017-12-08T14:51:41-05:00

Please review and sign below.

    Authorization and Consent for Medical Treatment, Payment Guarantee, and Acknowledgment of Receipt of Notice of Privacy Practices

  • As a patient of Diabetes Care Center, I understand that the office has an obligation to provide screening and emergency medical treatment when appropriate and to provide appropriate care and treatment of all patients. I hereby authorize DIABETES CARE CENTER, and its affiliated physicians and mid-level providers in charge of my case to administer any and all necessary or advisable treatments as may be deemed necessary or advisable in the diagnosis and treatment of any disease, disorder, or condition.
  • I authorize DIABETES CARE CENTER to bill my insurance company or other designated third-party payer for the services provided as related to my care. I acknowledge that DIABETES CARE CENTER will file claims on my behalf as a courtesy and that I as guarantor of the account remain responsible for payment of services. I acknowledge that I am also responsible for deductibles, co-insurance amounts, co-payment amounts, and non-covered services. I/we agree to pay the established rates of the clinic for all services rendered for the patient named below. I also acknowledge that I am aware that DIABETES CARE CENTER may have policies for financial counseling and assistance.
  • I do hereby authorize DIABETES CARE CENTER to release medical or other information to any insurance companies involved or any other agency assisting in the payment for the patient’s care. I understand that my information may be released by law for any activity related to the treatment, payment and operation activities related to my care. I also authorize the healthcare providers of DIABETES CARE CENTER to release medical and other information to other healthcare providers or facilities as needed for emergency treatment or continuity of care. Unless otherwise restricted by me, as patient or guardian, health information may also be released to immediate family members who are actively engaged in the management of my care. I acknowledge that I will need to authorize a more specific release of information if the HPI is to be used for reasons other than emergency treatment, payment and business operations.
  • By signing this form, you acknowledge receipt of the notice of privacy practices of DIABETES CARE CENTER. Our notice of privacy provides information about how we may use and disclose your protected health information. We are required by federal law to obtain your acknowledgement that you have received this Notice. If you have any questions about our notice of privacy practices, please contact us at the above telephone number.
  • THE UNDERSIGNED CERTIFIES HE/SHE HAS READ AND UNDERSTANDS THE ABOVE INFORMATION/AUTHORIZATION. IT ALSO CERTIFIES YOU HAVE RECEIVED OUR NOTICE OF PRIVACY PRACTICES. THIS AUTHORIZATION/ACKNOWLEDGEMENT REMAINS IN FORCE UNTIL SUCH DATE THAT IT IS REVOKED OR REPLACED.