Statement of Understanding 

 
 
 

Review each area:

Payment Agreement:  For and in consideration of services rendered by Accordia Health & Wellness, patient (responsible person) herby agrees to and guarantees payment of all Accordia charges incurred for the account of the patient from the date of admission until discharge.  I understand that if an agency or company is responsible for payment of services, that agency or company will have the right to review the services I receive at Accordia. I also understand that I may be charged a fee or co-payment for services and that it is expected, if I am responsible for the payment of these services, to pay for them as they are received. I further understand, I should contact Accordia if there are any change to my insurance. 

Methods of Payment – Our office accepts the following payment methods: Cash, Personal Check, Credit Cards, and Money Orders. There will be a $25.00 charge for all returned checks.

Health Information Exchange (HIE): Accordia Health & Wellness participates in a HIE called Care Quality. I understand that any physician or hospital that participates in the Care Quality HIE either directly or indirectly may request for the purpose of my continuity of care the following limited set of records regarding my care: Allergies, Demographics, Labs, Immunizations Medications, and Problem Lists. You many chose to Opt-Out of allowing your health information to be shared through the Care Quality HIE by requesting an Opt-out Form.
All other releases will follow the practices explained in Your Notice of Privacy Practices.

No Show Fee:  I understand I will incur a $50.00 no-show fee for any missed appointment that I do not supply a 24 hour advance notice of cancellation. Any further appointments will not be scheduled until the no-show fee has been collected. 

Fee Schedule:  I understand that I am responsible for payment for services rendered by Accordia Health & Wellness at its standard rates provided to me on the fee schedule. 

Self-Pay – I agree to pay Accordia in full for services rendered.   

Medicaid (if applicable):  Patient certified that the information given in applying for payment under Title XVIII (18) of the Social Security Act is correct.  Patient authorizes any holder of medical or other information about Patient to release to the Social Security Administration or its intermediaries or carries any information needed for this or a related Medical claim.  Patient requests that payment of authorized benefits be made on his/her behalf.

Medicare (if applicable):  Patient certified that the information given in applying for payment under Title XVIII (18) of the Social Security Act is correct.  Patient authorizes any holder of medical or other information about Patient to release to the Social Security Administration or its intermediaries or carries any information needed for this or a related Medical claim.  Patient requests that payment of authorized benefits be made on his/her behalf.

Assignment of Insurance Benefits and Agreement to Pay Any Balance: Patient (responsible party) irrevocably assigns and transfers to Accordia all right, title and interest to medical reimbursement benefits under any and all applicable medical insurance policies covering patient, for the payment of treatment and medical care being provided.  Patient (responsible party) authorizes payment directly to Accordia Health of said medical reimbursement benefits. Patient (responsible party) is responsible for and co-payments, co-insurance, deductibles, and/or other amounts specified by my insurance. In the event the said medical insurance I understand that my agreement with my insurance carrier is a private one, and that Accordia Health & Wellness does not routinely research why my insurance carrier has not paid or why it paid less than anticipated for care.  I understand that I am responsible to know my individual insurance coverage.  Please remember your insurance policy is between you and your insurance company and not with the insurance company and your doctor.

Consent for Residents, Interns, and Medical and Nursing Students to Participate in my Treatment:  I am aware that, residents, interns, medical and nursing students, could be present for educational purposes. I understand that in the educational process they may observe or participate in my or my child’s treatment and/or review my or my child’s medical record.

Consumer Rights Statement:  I understand that Accordia Health & Wellness subscribes to a Consumer Rights Statement, which has been made available to me. I have had the opportunity to have the Consumer Rights Statement explained to me.

Grievance Process:  I have been furnished with a copy of the Grievance process and have had the opportunity to have it explained to me. 

Procedure to Review Records:  I have been furnished with a copy of the Procedure to Review my health record and have had the opportunity to have it explained to me. 

Notice of Privacy Practices:  I have been furnished a copy of the Notice of Privacy Practices and have had it explained to me.  I understand that the information concerning my treatment will be held in confidence by the Accordia Health & Wellness staff unless I give specific written consent for the release of information.  In case of emergency Accordia Health & Wellness is authorized to request or release that information which is essential to handle the emergency. 
Also, Accordia Health & Wellness staff will not release any information except as required by law or Court Order under compelling disclosure, or in a situation deemed potentially life-threatening, and in the following instances:  Suspected Child Abuse, threats of physical harm to self and/or others, espionage or sabotage.
The confidentiality of your participation may also be protected by federal and state laws and regulations.  The violation of federal requirements is a crime, and suspected violations may be reported.  Federal regulations do not protect from disclosure of information related to a consumer’s commission of a crime against Accordia Health & Wellness property or personnel, or reports under state law of suspected child abuse or neglect (See 42 U.S.C. 290 ee 3 for federal laws 42 CFR Part 2 for federal regulations).

Rehabilitation Act:  It is the policy of Accordia Health & Wellness, in compliance with Section 504 of the Rehabilitation Act of l973, to afford qualified handicapped persons an opportunity to receive benefits or services that are equal to that offered non-handicapped persons.  Any person who feels he/she has not received treatment in accordance with this policy may submit a compliant with the Patient Relations Specialist, AltaPointe Health, 5750-A Southland Drive., Mobile, Al.  36693.

Advance Directives:    I have a medical advance directive and have provided a copy to Accordia.   I do not have a medical advance directive, and have been provided information by Accordia. 

Primary Care Telehealth Services:  I have been furnished information regarding Telehealth. I understand that the information obtained while using Telehealth may be used for diagnosis, therapy, follow-up, referral, and/or consultation, and may include one or both of the following: Live two-way audio and video and output data from medical devices and sound and audio files. The interactive tele-video equipment and telecommunication lines used are HIPAA approved for consumer security and privacy. I understand the expected benefits and potential risks of participating in Telehealth. I also understand that my telehealth services will be provided by a Accordia Health Credentialed Staff. 
 
Click the following link to review the referenced formsAccordia Health & Wellness Patient Policies
 
** **By signing below, I agree and have reviewed the Statement of Understanding and consent forms required by Accordia Health & Wellness. **
 

Reset Signature

Patient Name:
 
 

Reset Signature

Guardian/Legal Representative Name: