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Financial Responsibility and Privacy Policy
CONSENT FOR MEDICAL CARE AND ASSIGNMENT OF BENEFITS<br/><br/>I hereby provide consent for all medical care and assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, private insurance, and any other health plan to Neighborhood Adult Healthcare. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all the information to secure the payment.<br/><br/>PRIVACY POLICY ACKNOWLEDGEMENT STATEMENT <br/>I hereby acknowledge that I have been made aware that Neighborhood Adult Healthcare has a Privacy Policy in place in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). <br/>As a patient, I understand and acknowledge the following: <br/><br/>1. Neighborhood Adult Healthcare has made this policy available to me for review, by posting a complete version in the waiting room <br/>2. Neighborhood Adult Healthcare has made me aware, that as a patient I am entitled to a copy of this Privacy Policy. <br/>Upon your review of the above statements, please sign at the bottom acknowledging that you are aware of the privacy policy, and have read and understand the acknowledgment form. If you desire a copy of the Privacy Policy, please request one at this time. <br/>NO, I do not want a copy, but acknowledge the Privacy Policy Exists <br/>Yes, I DO want a copy of the Privacy Policy<br/>
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