Patient Consent for Use and Disclosure of Protected Health Information As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA), Effective April 14, 2003.
With my consent, the office of IKE ENI, MD PA, may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to IKE ENI, MD PA’s Notice of Privacy Practices for a more complete description of such uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent. IKE ENI, MD PA reserves the right to revise its Notice of Privacy Practices at any time. A Notice of Privacy Practices may be obtained by forwarding a written request to: IKE ENI, MD., PA., 9319 Pinecroft Dr. Ste. 120, The Woodlands, Texas 77380.
With my consent, the office of IKE ENI, MD PA, may call my home or other designate location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including for example, laboratory results.
With my consent, the office of IKE ENI MD PA, may mail or email to my home or other designated location any items that assist the practice in carrying out TPO such as appointment reminders and patient statements. I have the right to request that the office of IKE ENI, MD PA restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
When making an appointment with IKE ENI, MD A, it is your responsibility to make sure that the physician is under contract with your insurance plan. Failures to confirm that the physician is not in your plan may result in being out of network and may make you responsible for the charges.
Please inform our receptionist at the time of making your appointment of any demographic changes, i.e. address, phone number, insurance information, etc. There will be a delay in the event changes are given to the receptionist at the time of arrival instead of at the time of making appointment as it will be necessary to obtain insurance verification of coverage and benefits in addition to updating our records prior to being seen. Failure to notify us immediately of such changes in demographic information, financial status and/or insurance coverage may result in you being responsible for any services not covered by your insurance carrier.
As a courtesy, please arrive for your appointment at least 10 minutes prior. If more than 20 minutes late, it may be necessary to reschedule your appointment to another day in order to prevent inconveniencing other patients. Upon arrival for each office visit, please be prepared to show the receptionist a copy of your most recent insurance card. You will be required to verify all demographic information upon check in. This will include verification of name, address, telephone numbers and all insurance information. Failure to submit accurate information in a timely manner may result in you being responsible to balance due.
Upon checking out, please be prepared to pay for current and/or previous balances on your account. Payment requested may consist of any out-of-pocket amounts associated with a current visit and/or a prior balance. For your convenience, we accept cash, check, and credit cards, i.e. Visa, Master Card, Discover and American Express. We will also schedule any future appointments necessary and arrange for referrals as requested by Dr. Ike Eni. Please allow 24-48 hours for completion of most referrals.
We are contracted with most insurance plans for your convenience. We will obtain insurance verification prior to your appointment based on the information provided. Insurance verification does not guarantee that your insurance carrier will pay for services provided. Payment of co-insurance, deductibles, and services not covered by your insurance is required at time of service. Balances not paid within 30 days of notification of insurance denial may be subject to a monthly service charge.
We allow 45 days from the date a claim is filed by our office for the insurance company to pay. If the insurance carrier has not pain within this time, you may be responsible for the entire balance, without further notice. We will not become involved in disputes between you and your insurance company regarding coverage and/or policy benefit criteria, i.e. deductibles, non-covered services, co-insurance, coordination of benefits, pre=existing conditions or “reasonable and customary” charges, etc. other than to supply factual information when necessary.
By signing this form, I am consenting to the office of IKE ENI, MD PA, for use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing anytime, except to the extent that the practice has already made disclosures in reliance upon my prior consent. If this consent is not signed, the office of IKE ENI, MD PA, may decline to provide treatment. I have read, understood, and agree to the above HIPPA and Financial Policies. I hereby attest that I have given and agree to provide current patient and insurance information and authorize release of information necessary for insurance filing and pre certification by signing this statement.