As of, today's date, 05/28/2023, I acknowledge having been provided a copy of the Patient HIPAA Acknowledgement and certify that I have read and agree to Total Health Medical Center's (THMC) Payment Policy. I agree and consent to treatment by Total Health Medical Centers which may be either in-person or via telemedicine/virtual visit. I am eligible for the insurance indicated on this form and I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to THMC all money to which I am entitled for medical expenses related to the services performed from time to time by THMC, but not to exceed my indebtedness to THMC. I authorize THMC to release any medical information to my insurance carrier or third party payer to facilitate processing my insurance claims. I understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency. A $35.00 returned check fee will be charged for checks returned due to insufficient funds. I choose to receive communications from THMC by text or e-mail at the number or address stated above, including but not limited to communications about appointments, feedback, treatment, and payment. I understand that such e-mails and texts may not be secure and there is a risk that they may be read by a third party. Comments submitted on surveys may be anonymously shared on the THMC Public Website.
MEDICARE BENEFICIARIES: I request that payment of authorized Medicare benefits be made to THMC. I authorize any holder of medical information about me to release to CMS and its agents any information needed to determine these benefits or the benefits payable for related services.
HIPAA Authorization For Release of Medical Records
Furthermore, I hereby voluntarily authorize the disclosure of information from my health
record as indicated on my release form.