Policies and Agreements

Consent for Release of Health Information I hereby permit Gynecological Care, to release and furnish all medical and financial data related to my care that may be necessary now or-in the future for purposes of treatment, payment, or healthcare operations to assist with, aid in, or facilitate the collection of data for purposes of utilization review, quality assurance, or medical outcomes evaluation purposes. Such information may be released to insurance companies, HMO’s, and PPO’s, managed care organizations, IPA’s, Medicare/Medicaid, or other governmental or other third-party payers, or any organizations contracting with any of the above entities to perform such functions.

Acknowledgment of Review of Private Policy I am aware of this office’s notice of privacy practices that explains how my health information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

Notice of Financial Responsibility By signing this document, I understand that I will have services rendered by the physicians and nurses of Gynecological Care. I understand that the services may be pre-authorized by my insurance company, however I understand that the pre-authorization does not constitute a guarantee of payment for the pre-authorized services. Therefore, if the insurance company should deem the service and/or procedure/procedures are medically unnecessary and deny payment after the services have been rendered, I will take full responsibility for payment of service. Our office will file an insurance claim for all reimbursable services to both your primary and secondary insurance carriers. Please remember that you are responsible for all deductibles, co-pays, and non-covered service amounts. We ask that you make any required payments at the time of check in. If you have any questions, feel free to ask our staff about our payment policy. I authorize the payment of my medical and surgical insurance benefits to the Center for Gynecological Care, LLC.