Pre-Register

Medical History: Please check any that apply

Current Medications & Allergies

CONSENT FOR RELEASE OF MEDICAL INFORMATION

I understand that I have rights regarding my protected health information. These rights are governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I have been informed and given the opportunity to review and secure a copy of the facility's Notice of Privacy Practice which contain a more complete description of the uses and disclosures of my protected health information.

I hereby authorize the release and disclosure of my protected health information for treatment or payment for health care operations. I understand that any and all records concerning my personal and medical history are the confidential property of Physicians Surgery Center.

I agree that Physicians Surgery Center may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payers for treatment purposes.

I also agree that by providing my cell phone number I am giving consent for Physicians Surgery Center to contact me by this phone number.

You may restrict the individuals or organizations to which your health care information is released and you may revoke your authorization to us at any time, however, your revocation must be in writing and delivered to our address.

CONSENT OF FINANCIAL RESPONSIBILITY

My insurance policy is a contract between my insurance carrier and myself. I am ultimately responsible for payment-in-full for all medical services provided to me. I acknowledge full responsibility for services rendered by Jackson Ophthalmology ASC LLC dba Physicians Surgery Center. I understand that payment of charges incurred is due at the time of service unless other definite financial arrangements are made prior to treatment. I agree to pay all collection and attorney fees, if applicable, in the event of default of payment of charges. I assign benefits to and authorize direct payment to Jackson Ophthalmology ASC LLC dba Physicians Surgery Center of which it is entitled. This also includes proceeds and benefits accruing under any settlement, structure or otherwise, or awarded in judgment for personal injuries caused by a third party for payment of services rendered by Jackson Ophthalmology ASC LLC dba Physicians Surgery Center. I agree to pay for all charges not paid pursuant to this agreement. I agree, in order for Jackson Ophthalmology ASC LLC dba Physicians Surgery Center and/or any of its Business Associates to service my account or to collect any amount I may owe Jackson Ophthalmology ASC LLC dba Physicians Surgery Center or any of its Business Associates, they may contact me at any telephone number associated with my account, including cellular numbers, which may result in charges to me. I may also be contacted by text message or email, using only the email address I provide. Methods of contact may include prerecorded/artificial voice messages and/or use of an automated dialing service.

1 understand that Jackson Ophthalmology ASC LLC dba Physicians Surgery Center will always attempt to resuscitate the patient and refer the patient to another facility which provides a higher level of care if necessary.