Groveton Family Medical - Notices
180 North Magee
Groveton, TX 75845
Phone: 936-642-0841
Fax: 936-309-0086
INSURANCE AUTHORIZATION AND ASSIGNMENT
I hereby authorize Groveton Family Medical Clinic to furnish information to insurance carriers concerning my illness and treatments and I hereby assign to
the physician all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by
insurance. I do hereby voluntarily consent to such diagnostic procedures, hospital care and medical, surgical, treatment by Groveton Family Medical Clinic
physician(s) physician?s assistant, nurse practitioners, or physician's designees as is necessary in his/her judgement. I acknowledge that no guarantees have
been made to me as the result of treatments or examination in this facility
MEDICARE LIFETIME SIGNATURE FORM
I request payment of authorized Medicare benefits on my behalf for any services furnished to me by Groveton Family Medical Clinic. I authorize any holder
of medical & other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related
services.
FINANCIAL POLICY
To reduce confusion and misunderstanding between our patients and the practice we have adopted the following financial policy. If you have any questions
about the policy, please discuss them with the office manager. We are dedicated to providing the best possible care and service to you and regard your
understanding of your financial responsibilities as an essential element of your care and treatment. Unless other arrangements have been made in advance.
full payment is due at the time of service.
MEDICARE AND MEDICAID
We have made prior arrangements with Medicare to accept an assignment of benefits and by law we must bill Medicare as primary insurance for you. At the
beginning of each year, you will be responsible for an annual deductible. You will receive a statement for your copayment (which is 20% of covered
services) and any amount applied to your yearly deductible. The clinic is allowed to bill Medicare for Nurse's visits (blood pressure check or lab draw).
Medicare will be billed, and you will be responsible for any copayment due. Please check with the office manager for information on billing your
supplemental insurance.
We do accept Medicaid. In order to receive this benefit, you must present an Insurance Card or Medical Care Identification (form 3087 or a Medicaid
Verification Letter form 1027) at the time of each visit.
AUTHORIZATION OF TREATMENT AUTHORIZATION FOR EXAMINATION AND TREATMENT:
The undersigned has been informed of the examination and/or treatment considered necessary for the patient named on this record and that the treatment
and procedures will be performed by the physician?s assistant or/and physician or employees of above-mentioned clinic. I hereby grant authorization for
treatment and/or procedures and the administration of local aesthetics, medications and all treatment deemed necessary. My signature above certifies that I
have read the above authorization and understand its content and it also certifies that I understand this is no guarantee of assurance made as to the results
that may be obtained.
CONSENT TO PERMIT TESTING AFTER A BLOOD OR BODILY FLUID EXCHANGE
During clinic care and treatmenthealth care providers and/or clinicians may be accidentally exposed to a patient's blood or body fluids (through a needle
stick, blood splatter, etc.). Communicable diseases, including HIV, Hepatitis, and others are known to be transmitted through accidental exposures such as
the above mentioned. In the event that this occurs the patient who is being treated at the time the accident occurs must be tested to see if they have the
existing diseases to take necessary action for the protection of clinic personnel. I understand and agree that if a worker is exposed to my blood or bodily
fluids through accident that my blood will be tested at no cost to me using a special decoded system for the HIV antibody test. The results of this type of
testing may improve the course of medical treatment and will not prejudice my patient relationship with Groveton Family Medical Clinic.
ACKNOWLEDGEMENT OF PHYSICIAN'S ASSISTANT:
I hereby authorize the supervising physician, James Cochran M. D. and the physician?s assistant, Keith Jones, P. A.-C and nurse practitioner, Lisa Proctor
FNP-C and/or any physician assistant employed by Groveton Family Medical Clinic to administer such treatment as is medically necessary.
ACKNOWLEDGEMENT OF OUTPATIENT TREATMENT:
I understand that the medical care which will be furnished to me in Groveton Family Medical Clinic will be limited solely as outpatient treatment. I
understand that I may be released to another physician's care before my medical issues are known or resolved and that it will be necessary for me to make
arrangements for follow-up care
RIGHT TO REFUSE:
I acknowledge I have the right to accept or refuse medical or surgical treatment.
NOTICE OF POSSIBLE NON-COVERAGE:
I understand that during patient treatment, Groveton Family Medical Clinic may provide care which is not covered by insurance of the Texas Medical
Assistance Program as being medically necessary for my care. I understand that the Texas Department of Human Services or its health insuring agent
determines the medical necessity for the services or items that the Groveton Family Medical Clinic deems necessary for proper patient care. I
understand that I am responsible for payment of the services of items requested and provided by the attending care provider that may be determined not
to be reasonable by insurance or medical program plans.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
I have reviewed this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am
entitled to receive a copy of this document upon request and there is a copy located in the lobby
NOTICE TO PATIENTS REQUESTING DISABILILBY FORMS:
The practitioners here at Groveton Family Medical Clinic are not specialist in occupational medicine nor psychiatric medicine. We do not possesscertain equipment at the clinic to determine residual, functional, or mental capacity for disability claims. As a result, we prefer not to complete forms for
disability, including but not limited to the following: Residual Functional Capacity Questionnaires, Mental or Psychological Capacity Questionnaires,
Arthritis Impairment Questionnaires
LIMITATION ON VISITORS IN EXAM ROOMS
Effective January 3, 2023 Due to space limitations in the exam rooms, please limit 1-2 people accompanying the patient into the exam room. We ask that
additional guests please wait in the waiting room. This is to ensure better time, more concentrated care, and attention to the patient.
PATIENT COMMENT POLICY
Patients of the clinic have the right to file a written comment regarding the performance of any employee of the clinic, and policy or procedure. To receive
the attention of the clinic owner, all comments must be in writing and signed by the person involved in the situation that necessitated the comment. The initial
comment letter shall be sent to: Dana Ayala. The office manager shall research circumstances detailed in the letter and respond in writing within thirty days
of receipt of the grievance letter. If the patient is not satisfied with the results of the first letter, they may then submit an additional letter to the clinic owner
requesting a face-to-face meeting with the clinic owner and all staff persons involved in the situation. If the patient is not satisfied with the results of the
meeting, then the patient may submit a written request to the clinic owner to terminate their patient- caregiver relationship with the clinic. Patients may
obtain a written copy of this policy by asking for the ?Patient Comment Policy? at the reception desk of the clinic.
PATIENT RIGHTS AND RESPONSIBILITIES
When you are seen by an employee or contractor of the clinic, you have the Right to: Be treated with consideration, respect and dignity; Have the
confidentiality of your medical information protected, to have privacy act regulations enforced, and to have these areas of confidentiality explained to you in
language you understand; Have privacy during case discussion, counselling and treatment; Review your records in the presence of a healthcare professional;
Know the name and qualifications of staff providing your care; Know your diagnosis. health problems, test results, the potential advantages and risks of
treatment or procedures in language you can understand; Expect that all services, treatment, and counseling techniques will take place with your informed consent; Participate in referral planning; Have access to the patient comment procedure; Refuse to participate in research; Have another individual present
in the exam room with you, if you so desire. When you are seen by an employee or contractor of the clinic, you have the Responsibility to: Treat the staff with
consideration, respect, and dignity. Understand that your lifestyle does affect your health. Take an active part in your health care. Follow the agreed upon
treatment plan. If you choose or are unable to follow the treatment plan, it is your responsibility to inform the Medical Provider. Observe facility rules and
regulations that are for the safety and consideration of all patients and staff. Provide accurate and complete information about present complaints, past
illnesses, hospitalizations, medications, advance directives (living wills or durable power of attorney), and other matters relating to your healthcare. Report whether you understand a contemplated course of action and what is expected of you.
WE ARE NOT A PAIN MANAGEMENT CLINIC
This clinic does not engage in the management of chronic pain medications for any patients, nor patients demanding controlled substances. We will not provide prescriptions of certain medications for patients who are seeking controlled substances such as Hydrocodone (Norco, Vicodin, Lorab. etc.), Tulenol with Codeine, Tramadol, Morphine, Oxycontin, Fentanyl (Duragesic), Stadol, adult ADHD medications, regular or frequent use of
Xanax, Klonopin, Valium, Ativan, etc. This clinic carries no narcotic injections for pain. We will be happy to provide a list of pain management facilities that we are aware of if you would like. We will also be happy to provide you with a list of clinics who treat substance abuse if you feel
you are addicted to certain medications, or if you are experiencing or about to experience with-drawl symptoms. It may be necessary to refer you to
a hospital Emergency Department if you are in uncontrollable pain. We ask that you and all patients pay their fee for the office visit before they are seen, and we do not offer refunds to patients when we decline requests for controlled substances. If you demand your medical record for today's
visit personally, please give us written notice and pay the appropriate fee for the record. We are allowed at least 30 days to comply with your
request. By signing below, you acknowledge that you have received this notice and that you are not here asking for, seeking, or demanding controlled substances.
Notice of Nondiscrimination and Accessibility
Groveton Family Medical complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex (consistent with the scope of sex discrimination described at 45 CFR § 92.101(a)(2)) Groveton Family Medical does not exclude people or treat them less favorably because of race, color, national origin, age, disability, or sex.
By signing below, I am confirming I have read and understand the above statements
