Special Instructions: • Register participant in Practice Velocity under

(Patient Must present Photo ID and Insurance Card at Time of Service)
Authorization for Prevention and Wellness Services
Patient Name:
Plan Name:
HumanaVitality
Plan Street Address: 5th Floor, 550 West Adams
City, State, Zip Code: Chicago, IL 60661
Prevention and Wellness services may include:
Biometric Testing
•
•
•
•
Special Instructions:
Register participant in Practice Velocity
under EPS
Ensure Humana Vitality is chosen as the
employer
Read detail and print protocol identified in
alert, and follow directions in the protocol
Obtain copy of participant’s insurance card
(back and front)
Authorization Form Expires 06/31/2012
Patient Authorization
Notice of
Privacy Practices
Medical Care/Treatment
Financial Policy
If you have
insurance…
Your name and signature below indicate that you have received a copy of Concentra’s Notice of Privacy Practices on the date and time
indicated. If you have any questions regarding the information in Concentra’s Notice of Privacy Practices, you may contact K Royal, Privacy
and Security Officer for Concentra, at toll free 800-232-3550.
Name (please print):
? Signature:
Date and time Notice received:
Unless you are here for employer paid services, you will be responsible for either full payment or payment as indicated by your insurance plan.
If Concentra has a contract with your insurance company we will file today’s charges with that insurance company. You will be responsible
today for your co-payment, coinsurance and/or deductible, and the cost of any services not covered by insurance. You may receive a bill
from Concentra for any unpaid balance.
If you do not
have insurance…
If you do not have insurance coverage or Concentra does not have a direct contract with your insurance company, you will be required to pay
in full for your visit today. You can expect to make a minimum initial payment of $95 to $105 for medical care/treatment based on posted
pricing in the center, which will be collected at your check-in.
Ü If your treatment requires more complex evaluations, labs, X-rays, or supplies, you will be charged for those in addition to the
appropriate office visit fee. These fees will be collected after service and treatment have been provided.
Release of
Medical Records,
Assignment of
Benefits,
Financial
Responsibility
I authorize Concentra to submit claims to my insurance carrier as well as medical records needed to evaluate these claims for payment. I
understand that if my employer is responsible for paying all or part of this claim, they will receive the medical information needed to pay
this claim and I authorize release of this information. I further authorize payment of benefits, otherwise payable to me, to be made payable
to Concentra. I understand that I am financially responsible for all charges not covered by my insurance.
If my insurance company is not in Concentra’s network or I have no insurance coverage, I understand that I am financially responsible for all
charges and must make full payment today.
? Signature of Patient/Guardian:
Consent for
Wellness and
Preventive Health
Screening
I give permission for Concentra to perform wellness and/or preventive health screening. I understand it is my responsibility to follow up
on the information I receive during my wellness screening with my personal physician or other healthcare provider of my choice. While
performing the wellness screen, Concentra does not assume responsibility for treatment or management of care.
? Signature of Patient/Guardian:
Consent for
Medical
Treatment
Date:
Date:
I give permission to Concentra Medical Centers to perform the medical and surgical processes, treatment, and/or procedures that the
physician and other non-physician providers and assistants may deem to be necessary. In addition, I authorize Concentra Medical Centers to
release any information obtained during the course of my examination and/or treatment to my health care insurer or other payer.
? Signature of Patient/Guardian:
Date:
Concentra.Com
Improving America’s health, one patient at a time.
Autorización Paciente
Declaración de
las Prácticas de
Privacidad
Su nombre y firma abajo indican que usted ha recibido una copia de la Declaración de las Prácticas de Privacidad de Concentra en la fecha y hora
indicados. Si usted tiene cualquier pregunta acerca de la información en la Declaración de las Prácticas de Privacidad de Concentra, puede contactar
a K Royal, oficial de privacidad y seguridad al número gratuito 800-232-3550.
Nombre (letra imprenta por favor):
? Firma:
Fecha y hora en que se recibió la declaración:
Política Financiera del
tratamiento médico
A menos que esté aquí por servicios pagados por el empleador, usted será responsable bien sea por el pago total o pago según esté indicado por su
plan de seguro.
Si usted tiene
seguro…
Si usted no
tiene seguro…
Autorización para
Acceder e
Intercambiar
Información Médica,
Asignación de Beneficios,
Responsabilidad
Financiera
Si Concentra tiene un contrato con su compañía de seguros nosotros le enviaremos la cuenta de hoy a esa compañía de seguros. Usted será
responsable hoy por su co-pago, co-seguro y/o deducible, y el costo de cualquier servicio que no esté cubierto por el seguro. Usted podrá recibir
una cuenta de Concentra por cualquier balance que no se haya pagado.
Si usted no tiene seguro o Concentra no tiene un contacto directo con su compañía de seguro, se le requerirá que pague el total de su visita de hoy.
Se espera que usted haga un pago mínimo inicial de $95 to $105, el cual le será recaudado al momento de registrarse.
Ü Si su tratamiento requiere más evaluaciones complejas, laboratorios, Rayos-X, o suministros, se le cobrará por aquellos servicios en adición
a la cuota apropiada por la consulta médica. Estos honorarios serán recaudados después de que el servicio y el tratamiento hayan sido
provistos.
Yo autorizo a Concentra a enviar reclamos a mi compañía de seguros así como la información médica necesaria para evaluar estos reclamos para
pago. Yo entiendo que si mi empleador es responsable por pagar todo o parte de este reclamo, ellos recibirán la información médica necesaria
para pagar este reclamo y yo autorizo la publicación de esta información. Adicionalmente, yo autorizo que el pago de beneficios, de otra forma
pagaderos a mi, le sean pagados a Concentra. Yo entiendo que yo soy financieramente responsable por todos los cargos que no estén cubiertos
por mi seguro.
Si mi compañía de seguros no está en la red de Concentra o yo no tengo cobertura de seguro, yo entiendo que soy financieramente responsable
por todos los cargos y que debo pagar el total hoy.
? Firma del Paciente/Guardián:
Consentimiento
para evaluación
de bienestar y
salud preventiva
Yo le doy permiso a Concentra para llevar a cabo evaluaciones de bienestar y/o de salud preventiva. Yo entiendo que es mi responsabilidad el
hacer seguimiento con mi médico personal u otro proveedor de cuidados de la salud de mi elección, acerca de la información que reciba durante my
evaluación de bienestar. Aunque se haga la evaluación de bienestar, Concentra no asume responsabilidad por tratamiento o la administración del
cuidado.
? Firma del Paciente/Guardián:
Consentimiento
para tratamiento
médico
Fecha:
Fecha:
Yo le doy permiso a los Centros Médicos Concentra para realizar los procesos médicos y quirúrgicos, tratamiento y/o procedimientos que el médico
y otros proveedores no médicos y asistentes consideren necesarios. Adicionalmente, yo autorizo a los Centros Médicos Concentra a acceder e
intercambiar cualquier información con mi asegurador de la salud u otro pagador, obtenida durante el curso de mi evaluación y/o tratamiento.
? Firma del Paciente/Guardián:
Fecha:
Concentra.Com
© 2010 Concentra is a registered trademark of Concentra Inc.
01/10 U/IC_PAF0110
Mejorando la salud en los Estados Unidos, un paciente a la vez.
Authorization for Use and Disclosure of
Protected Health Information — Wellness
Specifying
Participant
and Event
My signature at the bottom of this page authorizes Concentra to use and disclose protected health information limited to the health assessment results
related to myself/individual and the event noted below. These results are for the purpose of wellness events, health risk assessments, biometric
screenings, and/or health improvement program services, but NOT for actual medical treatment of any identified health risks or conditions.
Participant/patient name:
Date of birth:
What happens
with my results
Concentra
My employer
A third party
Date services are rendered:
I understand that these screening results will be used by Concentra and its workforce.
I understand that my employer will receive a list of participants and aggregate results, but that personal health information of individual participants
will not be shared by Concentra with my employer unless my employer’s program requires my health assessment results or a subset of the results.
In that event, my employer will be listed here:
I understand that to assist in developing health improvement programs, screening results may be communicated to the following third party:
Name:
NOT APPLICABLE
Address:
City:
State:
Zip Code:
Ü I understand that if any third party receiving this informaiton is not governed by HIPAA, then my information will no longer be protected
by HIPAA once they receive it. Therefore, they could disclose my information to other parties, including, but not limited to, my employer.
Revoking
Authorization
I understand that I may revoke this authorization in writing at any time except to the extent that Concentra has already relied on this authorization.
By mail:
By fax:
Concentra
(214) 775-4408
ATTN: Privacy and Security Officer
ATTN: Concentra Privacy and Security Officer
5080 Spectrum Drive, Suite 1200 West
Addison, Texas 75001
Ü
Refusal to Screen
Signature
Authorization
Unless otherwise revoked, this authorization expires one year from the date of service.
I understand that Concentra may not refuse to conduct my Screening based on my completion of this authorization form except when the provision
of health care is solely for the purpose of creating protected health information for disclosure to a third party. For example, Concentra may have a
contract with a third party to provide Health Screenings, however, Concentra may refuse to conduct my screening if I do not sign this authorization
to permit Concentra to release the results of the exam to the third party.
? Signature of Patient
Date
-or-
? Signature of Patient’s Representative
Date
Printed Name of Patient’s Representative
Relationship to Patient and how you have the legal right to sign
Improving America’s health, one patient at a time.
©2010 Concentra Operating Corporation. All rights reserved.