Patient Consent
for Use and Disclosure of Protected
Health Information
Purpose of Consent:
By signing this form,
you will consent
to our use and disclosure of your protected health information to carry out
treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right
to read our Notice of Privacy Practices before you decide whether to sign this Consent, on the Ascend
website. Our Notice
provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected
health information, and of other important matters
about your protected
health information. A copy
of our Notice is accessible on the Ascend website. We encourage you
to read it carefully and completely before signing this Consent. We reserve the
right to change our privacy practices as described in our Notice of Privacy
Practices. If we change our privacy practices, we will issue a revised Notice
of Privacy Practices, which will contain
the changes. Those
changes may apply
to any of your protected health information that we maintain. You may obtain a copy of
our Notice of Privacy Practices, including any revisions of our Notice, at any
time by contacting:
Contact: Ascend Medical
Telephone: 888-250-5709
Email: ascend_privacy@ascendmedical.com
Address: 619 Rankin St NE Atlanta GA 30308
Consent for Counseling
I understand the
services I will receive may include psychotherapeutic assessment, supportive
clinical treatment and/or coordinated
referral if necessary. The treatment will be conducted
in an individual, family or
group therapy session as determined to be most appropriate by the
therapist. Sessions may occur on-site or by telemedicine if you are eligible. I
understand the therapist will maintain confidentiality of information
related to my case and only discuss or release
such information as provided by informed consent and signed release
authorizations. Services will be provided
at a negotiated hourly rate as agreed upon by me and the therapist
and may include or not include
insurance billing. I give my permission to all
Ascend Medical and Ascend Medical Behavioral Health staff to communicate freely
about my case in the interest of the best integrative care.
My signature on this
form signifies my
understanding and agreement with the above.
Consent to Obtain Patient
Medication History and Share Data
Patient medication
history is a list of prescriptions that healthcare providers have prescribed
for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. The collected information is stored in the practice
electronic medical record system and becomes part of
your personal medical record. Medication history is very important in helping
providers treat your symptoms and/or illness properly and avoid potentially
dangerous drug interactions.
It is very important
that you and your provider
discuss all your medications
to ensure that your recorded medication history is 100%
accurate. Some pharmacies do not make prescription history information
available, and your medication history might not include drugs purchased
without using your health insurance. Also, over-the-counter drugs,
supplements, or herbal remedies that you take on your own may not
be included.
I give
my permission
to allow
my healthcare
provider to
obtain my medication and
medical history from my pharmacy, my health
plans, and my other healthcare providers.
Consent Medication History: The patient
consents to the provider importing
their medication history
as provided by Surescripts.
Consent to Share Data: The patient has consented to share data with a public health agency.
Consent to Share
Data with HIEs: This patient
has consented to share their data with a Health Information Exchange.
By signing this consent
form you are giving your healthcare provider
permission to collect and share your pharmacy and your health insurer information
about your prescriptions that have been filled at any pharmacy or covered
by any health insurance plan. This includes
prescription medicines to treat
AIDS/HIVand medicines used to treat mental health issues such as depression.
Assignment of
Benefits and Payment
RELEASE OF
INFORMATION: I authorize Ascend Medical to disclose and
release to my insurance carrier(s), including Medicare, Medicaid,
Medigap/Supplemental benefits providers, and private insurers, as applicable,
any medical and treatment information needed for payment purposes for services
rendered. I authorize use of this form for the release of information needed to
process claims to all my insurance carrier(s) and its authorized agents. I
authorize my provider/practice to act as my agent in helping obtain payment
from my insurance companies.
ASSIGNMENT OF
BENEFITS: I assign all payments, rights and claims for
reimbursement of claims, costs and expenses allowable under my insurance
plan(s) directly to my provider or practice for services rendered. I understand
I will receive a statement for any balance due by me and I agree to make full
payment upon receipt of the statement after insurance has met its obligation.
AGREEMENT OF
RESPONSIBILITY: I understand that COPAYMENT and DEDUCTIBLE
IS DUE AT THE TIME OF SERVICE (coinsurance may also be collected at the
time of service). I understand I am financially responsible for charges not
covered by my insurance company. I also agree to pay any outstanding balance as
well as attorney fees and costs to Ascend Medical if this matter is referred to
collection.
MEDICARE
AUTHORIZATION: If a Medicare beneficiary, I understand my
signature requests payment to be made and authorize the release of medical
information necessary to pay claims. If ‘other health insurance’ is indicated
in item 9 of the HCFA-1500 Form, or elsewhere on approved claim forms, or
electronically submitted claims, my signature authorizes the release of
information to insurance companies or its authorized agents. In
Medicare-assigned cases, the physician or supplier agrees to accept the charge
of determination of the Medicare carrier as the full charge, and I agree I am
responsible for deductible, coinsurance and non-covered services. Coinsurance
and deductibles are based upon the charge determination of the Medicare
carrier.
MEDICARE LIFETIME AUTHORIZATION: I certify that the information given to me in applying
for payment under Title XVII of the Social Security
Act is correct. I authorize any holder of medical information about me to
release to the Social Security Administration of its intermediaries or carriers
any information needed for this or a related Medicare
claim. I request
that the payments
of authorized 
be paid on my behalf. I assign
the 
payable for services to the physician
or organization furnishing the services or authorize
such physician or organization to submit a claim to Medicare for payment.
I have fully read and
understand the above payment policy. I agree to forward to Ascend Medical all
insurance or third-party payments that I receive
for services rendered
to me immediately upon receipt.
Telehealth Consent Form
By signing, I
authorize Ascend Medical to use appropriate telecommunication technologies for
the purposes of evaluating and diagnosing my medical condition
and any health complaints. I understand that technical issues may arise before or
during telehealth sessions and, on occasion, my appointments may not start or end at agreed-upon times. I accept
that medical professionals will attempt to contact me using
video conferencing software. However, I also understand that other
communication channels, such as telephone calls, may be used in case of
internet connectivity or other issues.
I understand that my insurance
plan may not encompass telehealth services. In cases where my insurance
plan does not cover any expenses which have been incurred, I will be personally
liable to cover these expenses.
I give Ascend
Medical permission to access my medical records for the purposes of ongoing
documentation, evaluation, and analysis. I understand that all confidential information will be kept private.
Consent for Treatment
I hereby authorize
Ascend Medical to use and/or
disclose my health
information which 
me, or which can reasonably be used to identify me to carry
out my treatment, payment, and healthcare operations.
Treatment includes but is not limited to the administration and
performance of all treatments, the administration of any needed anesthetics,
the use of prescribed medication, the performance of such procedures as may be
deemed necessary or advisable in the treatment of this patient such as
diagnostic procedures, the taking and utilization of cultures and of other
medically accepted laboratory tests, all of which in the judgment
of the attending physician or their assigned
designees may be considered medically necessary or advisable.
Healthcare Operations include but are not limited to the
release of my medical information to any of my physicians and their offices
or insurance companies
participating in my care or treatment and the quality
of that care.
I understand that this is given in advance of any 
diagnosis or treatment and that these services are voluntary and that I have the right
to refuse these services.
I intend this
consent to be continuing in nature even after a specific diagnosis has been
made and treatment recommended. This consent will remain in full force unless revoked
in writing and will not affect
any actions that were taken
prior to receiving
my revocation. Patient
and/or guarantor are responsible
for charges incurred. It is a courtesy for our office to 
le with your insurance; however,
you are responsible for your co-pay
and or percentage which the insurance is not responsible for on the day of your visit.
If we are unable to obtain payment within a reasonable amount of time
from the patient/guarantor, we will place your account with a collection agency
which will leave you liable for any additional charges incurred.
I have fully read and
understand the above payment policy. I agree to forward to Ascend Medical all
insurance or third-party payments that I receive
for services rendered
to me immediately upon receipt.
Communications: With this consent, the Practice may call me, email or text
me to my home or other alternative location and leave a message by voice, email,
text or in person in reference to any items that
assist the practice in carrying
out TPO, such as appointment reminders, insurance items and anything pertaining to my clinical care,
including laboratory test results.
Medical Appointment Cancellation/No Show Policy
This authorization
will remain in effect until it is cancelled. When you schedule an appointment
with Ascend Medical, we allow ample time to provide you with one-on-one quality
care. Should you need to cancel or reschedule an appointment please contact our
office as soon as possible, and no later than 24 hours prior to the scheduled
appointment. This allows Ascend to schedule other patients who have requested
an appointment.
Effective April 2023, any established or new patient who
fails to
show or
cancel/reschedule an appointment with less than 24 hours’ notice will be identified
as a no show. A no show or cancellations with less than 24 hours’ notice may result in a $49 charge and $99 charge for therapy sessions. The fees are charged to the patient and not to the insurance company.
As a courtesy, we
send text messages, make calls, and send emails to remind our patients of their
appointments. If for some reason
we are unable to complete
the reminders, the stated policy
will remain in effect.
We are aware that there may be unforeseen emergencies that occur and do not allow you to provide the 24-
hour notice required. If you should experience extenuating circumstances please
contact our practice manager, who can assist with review and support.
Credit Card Authorization Form
Our authorization
will remain in effect until it is cancelled. Ascend Medical has worked to
provide services to patients and work directly
with your insurance company.
As a part of our agreement
with our patients and the insurance company,
all services may not be fully covered.
We request that a credit
card is on file to pay for all out-of-pocket costs,
co-pays, deductibles that may be part of your plan. The card will only be
charged if there are copayments or coinsurance that are due after billing the
insurance. Once the EOB is received and the payer allocates patient
responsibility, the credit card on file will be charged a maximum amount per
month of $450 toward the patient responsibility until the balance is $0.
By signing, you authorize Ascend
Medical to charge your credit
card for agreed upon services and products and understand that the
information provided will be saved for future transactions on your or your dependents account.
Patient Consent for Medicare Care Coordination Programs
(Chronic Care Management, Behavioral Health Integration, Remote Patient Monitoring, and Advanced Primary
Care Management)
Introduction:
Your healthcare provider may use one or
more of Medicare’s care coordination programs, namely: Chronic Care Management (CCM), Behavioral Health
Integration (BHI), Remote Patient
Monitoring (RPM), and Advanced Primary Care Management (APCM), to support your ongoing
health and well-being. These services are designed to coordinate care, improve
health outcomes, and ensure you have the resources and support you need.
What are These Services?
1.
Chronic
Care Management (CCM) covers:
a.
Regular
communication with your care team.
b.
Development
and monitoring of a personalized care plan.
c.
Coordination of care with other healthcare providers.
d.
Medication management.
e.
Assistance with transitions of care following hospital or specialist visits.
2.
Behavioral
Health Integration
(BHI) covers:
a.
Coordination and integration of behavioral health care with your primary care.
b.
Monitoring and management of mental health conditions.
c.
Access
to behavioral health specialists as needed.
3.
Remote
Patient Monitoring (RPM) covers:
a.
Use
of technology to monitor
your health status remotely.
b.
Regular review
of health data (e.g., blood pressure, glucose
levels) by your care team.
c.
Timely intervention based on health data trends.
4.
Advanced Primary Care Management (APCM) covers:
a.
Enhanced primary care services tailored to your unique needs.
b.
Proactive management of chronic conditions.
c.
Preventive care and health
d.
Your education.
Rights and Responsibilities:
- Your health data will be securely stored
and only accessible to authorized healthcare providers in your care.
- Participation in these services is voluntary. You may revoke
your consent at any time by notifying our office in
writing.
- You will have 24/7 access to your care team for
urgent needs. Please note that these care coordination services do not replace emergency care. In the case of an emergency, call 911.
- Summaries of your care plans will be shared with you and
updated regularly.
- Cost and
Billing Information:
o
Medicare Part B covers
these services, and you will be responsible for any applicable coinsurance or deductible.
o A monthly fee may apply, which is determined based on Medicare guidelines.
o These services will be billed under the supervision of your primary healthcare
provider.
Acknowledgment and Consent:
By signing
this form, you acknowledge the following:
- You understand the nature
and purpose of these services.
- You consent
to participate in CCM, BHI, RPM,
and APCM services provided by our care team if
they are deemed necessary to enhance your wellbeing.
- You authorize Medicare to be billed for these services
and accept responsibility for
any applicable costs.
- You understand that this consent will remain in effect until you choose to revoke it.
If you have questions or concerns about
these services, please
speak with a member of your care team.