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Acknowledgement of receipt of Notice of Privacy Practice regarding protected health Information:
I have received the Practice’s Notice of Privacy. Photocopies of this document are to be as valid as the original. Fundraising & Marketing: Unless you request us not to, we will use your name and address to support our fund-raising or marketing efforts. If you do not want to participate in fund-raising or marketing efforts, please check off the following box.


Assignment of Benefits:
I acknowledge financial responsibility for all facility and physician fees. I understand that the physician billing office will file my insurance claim and I assign direct payment to the physician all payments made under the terms and provisions of my policy. I further understand that any disputes on coverage are between my insurance carrier and myself and I will be responsible for payment for denied services regardless of the outcome of my dispute. I acknowledge financial responsibility for all charges if inaccurate insurance information is given at time of service and the information is not corrected prior to my insurance company’s timely filing limit.


Medical Records Exchange:
CHWPLC participates in one or more Health Information Exchanges (HIE). HIEs are electronic networks that securely provide and retrieve access to your health records for a better picture of your health needs. CHWPLC Providers, as well as other healthcare providers, may provide and retrieve access to your health information through an HIE for treatment, payment or other healthcare operations. As a CHWPLC patient, you have the ability to opt out of any HIE at any time by notifying a CHWPLC Associate. This is a voluntary agreement. Unless you advise us differently, your information may be accessed through an HIE by your CHWPLC provider.


Rx-History Consent:
I understand that performing a medication reconciliation in order to prevent adverse drug interactions and overdose is a critical component to my care. By initialing this section, I authorize my provider to query and review my medication fill history including drug, dose, form, strength, prescribing provider, and pharmacy.


Communication Preferences Regarding PHI
To assist in your care, it may be necessary to release our Protected Health Information to someone other than yourself. To whom may we talk? Please Check boxes and write in name(s).

  Yes   No  


Preferred method for appointment remind: Check all that apply


By typing my name below as my signature I consent to submit this information to Community Health & Wellness Partners. I may be contacted by an employee of CHWP to validate my identity. I am not required to sign this form in order to submit it, but will be asked to sign a paper copy of it prior to receiving services.