PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

With my consent, North Point Pediatrics may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to North Point Pediatrics’ Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review/receive the Notice of Privacy Practices prior to signing this consent. North Point Pediatrics reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to North Point Pediatrics, Privacy Officer at 11975 Morris Rd., Suite 210, Alpharetta, GA 30005.

With my consent, North Point Pediatrics may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, North Point Pediatrics may mail to my home or other designated location any
items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

With my consent, North Point Pediatrics may e-mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that North Point Pediatrics restrict how it uses or discloses my PHI to carry out TPO.

By signing this form, I am consenting to North Point Pediatrics’ use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, North Point Pediatrics may decline to provide treatment to me.

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  Signature Of Parent Or Legal Guardian         Print Name Of Parent Or Legal Guardian

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  Patient's Name                                                    Date      

INSURANCE STATEMENT/FINANCIAL RESPONSIBILITY
I understand that North Point Pediatrics will bill insurance companies for which they are providers, and verify the insurance information on those insurance plans which they are contracted, prior to services as allowed. My child(ren’s) insurance ID cards must be presented each and every visit. I am responsible for all balances my insurance carrier does not pay within 90 days. In the event my account becomes delinquent and is referred to any third party for collection effort, I agree to pay all reasonable attorney’s fees, court cost and collection expenses applicable on referred balance. In the event a physician is requested for a court appearance, I am responsible for physician fees not paid by my attorney or representing parties. If a check is returned on my account, I am aware that my account will be charged an additional $35.00 fee. And if I cancel (shorter than 48 hours notice) or do not show three (3) consecutive times for well care appointments, I understand that my account will be charged $75.00.

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Signature of Parent Or Legal Guardian                 Date