OHANA · _____ Ohana Health and Wellness does not provide emergency medical care. If you are...
2
OHANA HEALTH AND WELLNESS DIRECT: 971-201-7993 fax: 1-844-766-1788 www.ohanahealthandwellnesspdx.com AUTHORIZATIONS AND OFFICE POLICIES Before treatment commences, please read and initial the following statements: CONSENT TO OBTAIN PRESCRIPTION HISTORY _______ I authorize Ohana Health and Wellness to download my Medication History. Through our Electronic Medical Records system with Athenahealth, Ohana Health and Wellness can import the last 13 months of your medication history. This information is downloaded from the pharmacy benefits manager utilized by your health insurance place. FINANCIAL POLICY ______ I understand that, regardless of my assigned insurance benefits, I am financially responsible for payment of services rendered to me. If the physician involved in my care accepts third-party reimbursement for all or part of the services I receive, I hereby agree to assign such benefits to Ohana Health and Wellness and authorize my insurance company to make payment directly to Ohana Health and Wellness. I understand that Ohana Health and Wellness may disclose a limited amount of health information to third-parties to obtain payment for the health care services provided. Please be aware that some insurance companies may determine treatment to be non- covered or find it not to be reasonable or necessary. If such a determination is made, you will be responsible for such services. We accept cash, checks, Visa, MasterCard, American Express and Discover. Returned checks incur a $50 processing fee. CANCELLATION AND MISSED APPOINTMENT POLICY _______ I understand that Ohana Health and Wellness requires 24 hours advanced notice to cancel or re-schedule an appointment. I understand a fee ($25+ depending on the appointment type) may be charged to my account for missed appointments or appointments cancelled with less than the required notice. FORM FEES _______ I understand that Ohana Health and Wellness may charge for the completion of forms that require either staff or physician time to complete. The charge for this service will start at $10 depending on the complexity and time required. This includes, but is not limited to medication forms, letters, and FMLA forms. The fee may be waived (excluding FMLA) if the form is presented at an appointment to see the physician. CONSENT TO CONTACT VIA EMAIL _______ To the extent that our new Medical Record software allows it, we may be able to contact you via email to remind you of appointments.
OHANA · _____ Ohana Health and Wellness does not provide emergency medical care. If you are concerned that you might be experiencing a medical emergency, please call 911 or go to
CONSENTTOOBTAINPRESCRIPTIONHISTORY_______IauthorizeOhanaHealthandWellnesstodownloadmyMedicationHistory.ThroughourElectronicMedicalRecordssystemwithAthenahealth,OhanaHealthandWellnesscanimportthelast13months
of yourmedication history. This information is downloaded from the
pharmacy benefits
managerutilizedbyyourhealthinsuranceplace.FINANCIALPOLICY______Iunderstandthat,regardlessofmyassignedinsurancebenefits,Iamfinanciallyresponsibleforpaymentofservicesrenderedtome.Ifthephysicianinvolvedinmycareacceptsthird-partyreimbursementforallorpartofthe
services I receive, I hereby agree to assign such benefits to
OhanaHealth andWellness and
authorizemyinsurancecompanytomakepaymentdirectlytoOhanaHealthandWellness.IunderstandthatOhanaHealthandWellnessmaydisclose
a limitedamountof health information to third-parties
toobtainpayment for thehealthcare services provided. Please be
aware that some insurance companiesmaydetermine treatment to be
non-coveredorfinditnottobereasonableornecessary.Ifsuchadeterminationismade,youwillberesponsibleforsuchservices.Weacceptcash,checks,Visa,MasterCard,AmericanExpressandDiscover.Returnedchecksincura$50processingfee.CANCELLATIONANDMISSEDAPPOINTMENTPOLICY_______IunderstandthatOhanaHealthandWellnessrequires24hoursadvancednoticetocancelorre-scheduleanappointment.
Iunderstanda fee($25+dependingon theappointment
type)maybechargedtomyaccount
formissedappointmentsorappointmentscancelledwithlessthantherequirednotice.FORMFEES_______
IunderstandthatOhanaHealthandWellnessmaycharge for thecompletionof
formsthatrequireeitherstafforphysiciantimetocomplete.Thechargeforthisservicewillstartat$10dependingonthecomplexityandtime
required. This includes, but is not limited tomedication forms,
letters, andFMLA forms. The
feemaybewaived(excludingFMLA)iftheformispresentedatanappointmenttoseethephysician.CONSENTTOCONTACTVIAEMAIL_______TotheextentthatournewMedicalRecordsoftwareallowsit,wemaybeabletocontactyouviaemailtoremindyouofappointments.
OHANAHEALTH AND WELLNESS
DIRECT: 971-201-7993 fax: 1-844-766-1788
www.ohanahealthandwellnesspdx.com
CONSENTTOCOMMUNICATEPROTECTEDHEALTHINFORMATIONIauthorizeOhanaHealthandWellnesstocommunicatemyprotectedhealthinformation(includingappointmentreminders)tomeviathefollowingmethods:______Detailedmessageonmyhomeansweringmachine.______Detailedmessageonmypersonallyidentifiablecellphonevoicemail.PHONECALLS/PATIENTPORTALMESSAGES_______Phonecallsandportalmessagesregardinganexistinghealthissuethatrequiresmorethan10minutesofattention
from your physicianwill incur a fee. Phone calls and portalmessages
regarding a newhealth issue,regardlessof the lengthof
timeandattentionrequired,willalso incura fee.
Phoneandpatientportalmessagechargesmaynotbebillabletoinsurance.Pleasenotethatnonewprescriptionswillbegivenviaphoneorpatientportalmessages.HOMEVISITS
_______Homevisitsaresubjecttoanadditionaltransportationfee.EMERGENCYCARE
______OhanaHealthandWellnessdoesnotprovideemergencymedicalcare.Ifyouareconcernedthatyoumightbeexperiencingamedicalemergency,pleasecall911orgotoyournearestemergencyfacility.Pleasecontactourofficethefollowingdaytoinformusofthedetailsoftheevent.SUPPLEMENTS______
Payment in full is expected at time of purchase. We appreciate you
supporting local businesses
bypurchasingyourprofessional,high-qualitysupplementsthroughOhanaHealthandWellness.
IunderstandthatIamnotrequiredtopurchaserecommendedsupplements
fromOhanaHealthandWellness.
Pleasenotewemaynotbeabletorefundanyproductonceithaslefttheclinicpremises.ACKNOWLEDGMENTToindicatethatyouhavereadandunderstandthesepolicies,pleasesignbelow._____________________________________________________________________________________________
___________________________________Patient/LegalGuardianSignature
Date_____________________________________________________________________________________________Patientname(Pleaseprint.Includelegalguardianifpatientisaminor)
