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  • Thank you for choosing Transitional Care Physicians of America (hereafter TCPA)and/or Chronic Disease Management (hereafter CDM) as partners, for your healthcare provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have developed this payment policy. Please review and sign below. A copy will be provided to you upon request.

    Insurance: Our providers are contracted with many of the local and national managed care plans, including Medicare. However, there are some plans that we do not currently have a contract with, if you belong to a plan we are not contracted with, our insurance/billing office will be glad to file a claim for you with the understanding the full payment is due at the time of service. Your claim will probably be applied to an out of network deductible or totally rejected. It is important for you to understand that the patient is ultimately responsible for the fees that are not covered by the insurance provider in that case. If you have questions concerning the coverage your plan has with TCPA and/or CDM, please contact patient relations with your insurance provider.

    Co-Payments and Deductibles: In consideration of the services rendered, the patient agrees to pay the amount not covered, including, but not limited to any co-payments and/or deductible applied by the insurance provider(s) to TCPA and/or CDM. Proof of Insurance: All patients must complete our patient registration form before seeing a provider with our practice. We must obtain a copy of your ID and current proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible

    Coverage Changes: If your insurance changes, please notify our office prior to your next appointment so we can make the appropriate changes.

    Claims Submission: We will submit your claims and assist in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. If is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

    Request for Care and Consent for Treatment: I request professional services from TCPA and/or CDM and consent to the care and treatment by TCPA and/or CDM as requested by my provider.

    Assignment of Insurance Benefits: I assign direct payment of any insurance benefits to TCPA and/or CDM, including Medicare, at rates not to exceed TCPA and/or CDM regular charges for such services for the medical and palliative services I receive. Chronic Care Management: Chronic Care Management services will be provided for eligible patients and this does entail authorization for the electronic communication of medical information with other treating practitioners and providers. I consent for my insurance to be billed for servicesrenderedfor

    Chronic Care Management: Chronic Care Management services will be provided for eligible patients and this does entail authorization for the electronic communication of medical information with other treatment practitioners and providers. I consent for my insurance to be billed for services rendered for Chronic Care Management.

    Psychiatric Collaborative Care: Psychiatric Collaborative Care services will be provided for eligible patients with a Collaborative Care Team, led by the primary provider with TCPA and/or CDM and includes the collaboration services of a psychiatrist partnered through TCPA and/or CDM which will develop and implement an individualized care plan, which entails authorization for the electronic communication of medical information with other providers within the Collaborative Care team providers. I consent for my insurance to be billed for services rendered by the Collaborative Care Team, including services from the psychiatrist within my care.

    Patient Authorization for Use and Disclosure of Protected Health Information

    I hereby authorize the following individuals (listed below) access to all health records obtained by Transitional Care Physicians of America. I understand that by allowing release of my records to individuals other than myself, I hereby release Transitional Care Physicians of America of any liability with regards to distribution of my records to individuals not listed below. I understand that my healthcare information is protected and will not be distributed or shared with any individual or healthcare entity not listed below. This agreement is valid for the duration of my relationship with Transitional Care Physicians of America and can be updated or modified at any time with written consent or amendment to this form. I understand that I will not hold Transitional Care Physicians of American responsible for the distribution or disclosure of any health information as I am allowing other non-medical individuals and/or corporate entities access to my medical record and any distribution by here aforementioned parties cannot be the responsibility of the healthcare provider or Transitional Care Physicians of America.

    By signing, I authorize Transitional Care Physicians of America to use and/or disclose certain protected health information (PHI) about me to (list name & relationship):

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