Authorization, Financial Obligation, & Consent

I UNDERSTAND I MAY RECEIVE SEPARATE BILLS FROM COXHEALTH, ITS AFFILIATED ENTITIES, AND CONTRACTED PHYSICIAN GROUPS.

Authorization to Share Information. I acknowledge a copy of the Notice of Privacy Practices has been made available to me. I understand it sets forth my rights regarding my medical information and how it may be used or disclosed. I authorize the review, copying, and release of any information in my medical or billing record(s), including information regarding the diagnosis or treatment of HIV, AIDS, mental illness or substance abuse, to any person or entity responsible for determining the necessity, appropriateness, payment, continuity of care, or other matters related to the treatment or services rendered to me. This includes the sharing and/or receiving of prescription information with a prescription database used for electronically prescribing medications, including prescriptions prescribed outside of CoxHealth, as well as any Health Information Exchanges partnered with CoxHealth. I further consent to the use of ambient listening by my care team for the purpose of enhancing quality of care and ensuring a better patient experience.
 

Medicare. I request payment of authorized benefits be made on my behalf to CoxHealth, and I authorize the Social Security Administration to release information regarding my eligibility for coverage under Medicare Part A and Part B, including but not limited to the effective date of such coverage, to CoxHealth. I authorize CoxHealth to obtain information from the Social Security Administration or other government agency regarding my entitlement to benefits and my health insurance claim numbers.
 

Financial Obligation. I understand and agree I am financially responsible for payment of all amounts due regardless of whether I have coverage through or from any health insurance carrier, managed care plan, health maintenance organization, self-insured health plan, Medicaid, Medicare, or any intermediary or other carrier (collectively “Insurance Provider”). I understand CoxHealth will submit claims for payment to my Insurance Provider, is authorized to complete any forms needed to obtain payment from said Insurance Provider, and that I will remain financially responsible for any amounts not paid by my Insurance Provider. I acknowledge any credit balance may be applied to any open account of which I am the patient and/or responsible party. For any past due accounts, I agree to pay interest at the legal statutory rate if the amount for which I am responsible is not paid within thirty (30) days of the date of billing. I understand any unpaid balance may be the subject of legal proceedings against me, my spouse, or another responsible party, even if no request for payment or any other attempt to collect has been made. As part of the unpaid balance collection process and to contact me about my care or for administrative purposes, I authorize CoxHealth and any of its agents to contact me at any telephone number or address, including email address, I have provided to CoxHealth using any manner, including the use of an auto-dialing device, pre-recorded message or text message. I understand the cost of collections on past due accounts, including reasonable attorney’s fees and court costs, will be included as part of my financial obligation and I hereby agree to pay such costs. This agreement shall be governed by Missouri law, with venue in Greene County, Missouri. I also understand, pursuant to the Missouri hospital lien statutes, that if my injuries were caused by the negligence or wrongful act of someone else, CoxHealth may have a lien on the proceeds of any claims or rights of action I may have against the individuals or entities which caused my injuries, and CoxHealth may have the right to enforce its lien for payment of services rendered rather than seek payment from any third-party payer. This agreement and my obligation hereunder will override any inconsistent provision in any Insurance Provider plan document, insurance card or related instrument.
 

Assignment of Insurance Benefits. To the maximum extent permitted by law, I assign to CoxHealth the benefits otherwise payable to me for any hospitalization, outpatient services, and clinical treatment from my Insurance Provider. I understand I am financially responsible if my Insurance Provider does not cover all of my charges and that nothing in any Insurance Provider plan document, insurance card or related instruments will preclude CoxHealth from enforcing its right to payment.
 

Consent for Treatment. I agree, request, and authorize CoxHealth to provide health care services to me and further consent to any examinations, tests (including for drugs and/or alcohol), or procedures that may be advisable or necessary for routine diagnostic purposes, or to diagnose or treat my medical condition. I realize that among those who attend to patients at CoxHealth facilities are medical, nursing, and other healthcare personnel in training who may be present and participating in my care as part of their education. I also understand that CoxHealth utilizes the services of non-physician practitioners, that I may be evaluated and treated by one of these non-physician practitioners and that I have the right to see that practitioner’s collaborating physician. I authorize the taking of photographs, videos, or other images of parts of my body for use in my medical evaluation, for education, and for security purposes. I am aware the practice of medicine is not an exact science and I understand no promise, guarantee, or warranty has been made regarding the results of the examination or treatment I receive. I agree to have my blood tested for hepatitis or HIV infection if my physician determines it is necessary or if an employee, provider, volunteer, contractor, treating physician, emergency worker, or law enforcement personnel is exposed to my blood or bodily fluids. If my blood indicates infection, my physician will be notified as well as any other individual, entity or agency required by law.
 

Release of Responsibility for Valuables. I understand CoxHealth strongly recommends all personal belongings and valuables not be kept in its facilities. I understand CoxHealth will not be liable for loss or damage to any personal property remaining in my possession and will not replace any personal items if they are lost or stolen.
 

Acknowledgments and Certifications. I acknowledge copies of the Patient Bill of Rights and Responsibilities and the Notice of Nondiscrimination has been made available to me. I certify I have read and understand all parts of this form; accept all its terms and conditions; warrant all representations made by me are true; and agree a copy of this form is effective and valid as the original.