Disclosure

Pre-Certification & Financial Responsibility: I understand that my insurer may review anticipated courses of treatment from Mertz MFM Center. I understand that if the insurer determines that the treatment plan is medically necessary and issues certification, my benefits will be available according to my policy terms. However, if certification is denied, benefits may be withheld. I understand that precertification may be the responsibility of the patient or financially responsible party and his or her referring physician. I also understand that I may be financially responsible for any charges incurred as a result of this treatment plan should the insurer either refuse to pre-certify the treatment, retrospectively determine that a service was inappropriate, or should the certification occur too late to be valid. I understand that to protect myself from unnecessary personal financial obligations, I must review my obligations with my insurance company and referring physician in advance of my appointment.

I have read understood and agreed to the above terms


Assignment of Benefits: In consideration of the services provided to me, I hereby assign and transfer to Mertz MFM Center all medical provider benefits payable and any related rights existing under my insurance policies. I authorize and direct the insurance company to pay all such benefits to Mertz MFM Center. I understand that this assignment does not relieve me of any responsibility I may have for payment of charges not paid by the insurance company, unless otherwise provided by the terms of an agreement between the insurer and Mertz MFM Center.

I have read understood and agreed to the above terms


HIPAA Acknowledgement & Consent: I understand that I have certain rights under the Health Insurance Portability & Accountability Act (HIPAA) regarding my protected health information (PHI). I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow-up care among all providers who may be involved, obtain payment from designated third-party payers, and conduct normal health care operations such as quality assessments or evaluations.


Authorization to Release & Share Medical Information: I hereby authorize Mertz MFM Center to release a copy of my complete health records covering the entire treatment period during which I received services from Mertz MFM Center to your referring provider.

I further authorize Mertz MFM Center to share limited health information with family or friends as identified below, for the duration of my treatment, and up to one year thereafter, unless I rescind such permission in writing:

I have read, fully understand, and consent to the above information in its entirety. By using an electronic signature, I demonstrate my acceptance of the information above. My electronic signature is as legally binding as my handwritten signature.

Patient or Guardian (where applicable) Signature:

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