Plastic + Hand Surgical Associates Page 1 of 2 244 Western Avenue, South Portland, ME 04106 (207)-775-3446

## PATIENT CONSENT &ASSIGNMENT FORM

- I. Consent to Treatment

I authorize Plastic + Hand Surgical Associates, Skin Solutions from Plastic + Hand and Western Avenue Day Surgery Center which is a division of Plastic + Hand Surgical Associates collectively referred to as Plastic + Hand, its health care practitioners, staff, ambulatory surgical facility and other individuals involved in my care to examine me and perform any tests, procedures and/or treatments that may be helpful to care for my injury or illness.

I understand that Plastic + Hand is dedicated to teaching, that authorized trainees may observe and assist in diagnosis, treatment and care, and that photographs may be taken for purposes of diagnosis, teaching and documentation. I reserve the right to give specific permission for publication of any picture that personally identifies me.

## II. Payment and Financial Obligation

I request that payment of authorized Medicare and/or other insurance company benefits be made either to me or on my behalf to Plastic + Hand for any services furnished to me by that physician/supplier. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If item 9d of the CMS-1500 Medicare form is completed (secondary carrier after Medicare), my signature authorizes release of the information to the insurer or agency shown. In Medicare and/or other insurance company assigned cases, the physician or supplier agrees to accept the charge determined of the Medicare and/or other insurance company as the full charge, and the patient is responsible only for the deductible, coinsurance and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare and/or the other insurance company.

I understand that I am responsible for paying all charges associated with this treatment. If I have health insurance, I understand that I am financially responsible in the event that all or some payment is denied by my insurance carrier or other third party who is responsible for payment. I am also responsible for these charges not covered by my insurance such as deductibles, co- pays or evaluations or treatment that are not included as an insurance benefit. I understand that if my insurance plan requires a referral, prior authorization for surgery and/or a second surgical opinion and this has not been obtained, I am responsible for payment of services rendered.

I authorize my health insurance carrier(s) or other third parties who are responsible for paying for my health care to pay costs associated with my evaluation and care directly to Plastic + Hand Surgical Associates.

I authorize the release of any medical information necessary to process this claim; I also request payment of benefits to Plastic + Hand. I realize that in the event the se claims are denied by Workers' Compensation, I am responsible for payment, and I authorize my private health insurance carrier to reimburse Plastic + Hand in the event that Workers' Compensation denies payment. I understand that in order to be in compliance with Title 39 MRSA 52-A (2), Plastic + Hand must furnish my employer with periodic medical reports. I authorize the release of information with the State M-1 from.

## III. CONSENT TO USE ANDDISCOLSURE OF PROTECTED HEALTH INFORMATION

I consent to Plastic + Hand Surgical Associates, Skin Solutions from Plastic + Hand and Western Avenue Day Surgery Center which is a division of Plastic + Hand Surgical Associates collectively referred to as Plastic + Hand, its health care practitioners, staff, ambulatory surgical facility and other individuals use and disclosure of my protected health information ('PHI') in support of my diagnosis and treatment, payment for the medical services I receive, and the legitimate health care operations of the medical practice.

## OVER OVER