*****Self-declared income will apply sliding fee discount for 30 days only. To be eligible for future discounted services financial documentation will be required.
To the best of my knowledge, the information given is true and correct. I give Rogue Community Health permission to verify information about my financial status. I understand this information must be updated annually to determine if my sliding fee scale discount has changed. Signature*
Consent for Treatment:
I consent to treatment necessary for the care of the above named patient. I authorize release of all medical records to referring health care providers and to my insurance company, if applicable. I allow fax transmittal and/or HIPAA secure electronic submission of my medical record, if necessary.
All insurance co-pays are due at the time of the visit. All patients with self-pay accounts are asked to bring in payment at each visit. Patients that have made payment arrangements and/or received a monthly statement must make a payment within thirty days of the statement date. If you have payment concerns, please notify the billing department. We will bill your insurance for you; however your account remains your responsibility.
I understand the financial policy above and accept financial responsibility. By signing below, I assign Rogue Community Health all payments due from my insurance company for services rendered.
Consent to Request Medical Care for Minors:
The following persons are authorized to access medical care for the child named above, for services not related to well-child or preventive services:
I have read and fully understand the above consent for treatment, financial responsibility, and release of medical information, insurance authorization, and consent to request medical care for minors. These agreements will remain in effect for one calendar year or until revoked by me in writing. If revoked, I understand the authorization will not affect any use or disclosure of information that has already occurred.
I authorize Rogue Community Health to use and disclose the health and medical information of patient name* for the purpose of Treatment, Payment and Health Care Operations.
* Treatment (includes activities performed by a provider, nurse, lab personnel, office staff, and other types of health care professionals providing care to you, coordinating or managing your care with third parties, and consultations with and between other health care providers. This consent includes treatment provided by any medical personnel who covers our practice by telephone as the on-call medical personnel.
* Payment (includes activities involved in determining your eligibility for health plan coverage, billing and receiving payment for your health benefit claims, and utilization management activities which may include review of health care services for medical necessity, justification of charges, pre-certification and pre-authorization).
* Health Care Operations (includes the necessary administrative and business functions of our office). Rogue Community Health is part of an organized health care arrangement including participants in the Oregon Community Health Information Network (OCHIN). Your health information may be shared by Rogue Community Health with other OCHIN participants when necessary for health care operations.
You may review Rogue Community Health’s “Notice Of Privacy Practices” for the additional information about the uses and disclosures of information described in this CONSENT prior to signing this CONSENT. Please verify that you have received a copy of our Notice by placing your initials below in the signature field.
Because we have reserved the right to change our privacy practices in accordance with the law, the terms contained in the Notice may change also. A summary of the Notice will be posted in our waiting room and web site indicating the effective date of the Notice in the upper right hand corner. We will offer you a copy of the Notice on your first visit to us after the effective date of the then current Notice. We will also provide you with a copy of the Notice upon your request.
As more fully explained in the Notice, you have the right to request restrictions on how we use and disclose your protected health information for treatment, payment, and health care operations purposes. We are not required to agree to your request. If we do agree, we are required to comply with your request unless the information is needed to provide you emergency treatment. Other medical personnel who provide call coverage for our office are required to use and disclose your protected health information consistent with the Notice.
Initials Here Signature*
I understand that I have the right to revoke this CONSENT provided that I do so in writing, except to the extent that Rogue Community Health has already used or disclosed the information in reliance on this CONSENT.
Signature of patient
(Or) Signature of person authorized by law
AS A PATIENT, I AGREE TO THE FOLLOWING:
• I agree to treat staff and clients of RCH with dignity and respect.
• I will arrive at specified arrival time for my appointment.
• I will cancel appointments at least 1 hour before appointment time or it will be considered a “No Show”.
• 2 “No shows” within a six month period could result in you losing privileges to schedule future appointments.
• I have been given the opportunity to ask any questions I have about my care through RCH.
• I can request a copy of all authorization documents such as Notice of Privacy Practices (HIPAA), Patient responsibilities, and RCH Responsibilities and Duties.
• I understand that children may not be left in the waiting area while I am being treated
• Payment is due at time of service unless previous arrangement has been made with RCH billing department
Signature Parent Legal Guardian*
Signature Please Print