The Right Care Right Here

Welcome Thank you for choosing Indian River Medical Center Physician Practices where we provide the right care right here. Whether you need an annual check-up, surgery, or have an injury that needs urgent care, you will find caring and compassionate primary care providers, specialists and staff members who will take the time to meet your needs.

Office Policies Initial Visit: Please complete the enclosed paperwork and bring with you, along with all the bottles of medications you are currently taking. We require your health insurance cards and a photo identification card. Past medical records are helpful at an initial visit, so you should request them from your doctors. We also require that you come in AT LEAST 20 MINUTES prior to your appointment to allow adequate time for our staff to prepare your patient record.

Follow-up Visit: To ensure your safety and the accuracy of your medical record, it is important to provide an up-to-date list of all medications, vitamins and herbal supplements at each visit. Please list the amount of the medication you are taking (the dosage) and how often you are taking it.

Refills: Please call your pharmacy to see if the prescription has been filled prior to calling the office. Patients should request prescriptions at least 24 hours in advance from the pharmacy. The pharmacy will fax the request to our office and we will in turn reply to their request. Prescriptions will not be filled on weekends or after 5:00pm Monday – Friday. After 12 months, a medical history update and exam are necessary for any refills. Antibiotics, steroids, and all addictive medications cannot be refilled without an office visit.

Referrals: If a referral has been made to another physician and you do not hear from that physician’s office within 2-3 days, please contact our office so that we can assist you in getting your appointment scheduled.

Laboratory Testing: Many times your physician will ask that you have “fasting” blood work .The definition of fasting is: nothing after midnight except water or medications. When the doctor orders blood work, please have it done no less than 1 week prior to your next appointment so that your lab results can be discussed with you when you come in.

Hospitalist Services: Our physicians work with the hospitalist service at IRMC when their patients require hospitalization. A hospitalist is a physician specialist in inpatient care who provides 24/7 care while you are in the hospital. We advise that you call our office when admitted so that we may follow on your progress during your hospitalization. Our collaboration with the hospitalists allows for a continuity of care and availability during office hours.

After hours: Bringing your concerns to our attention during office hours will ensure the problem is dealt with sooner and a prompt follow-up is scheduled. For urgent matters, you should go to the Emergency Department for any medical emergencies.

Primary Care South - Oslo

4165 9th Street SW, Suite 106

Vero Beach, FL 32968

772.569.7706 PHONE

772.569.7752 FAX

www.irmcphysicians.com

Dennis King, M.D.

IRMC-Physician Practices

Patient Registration Form P

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Name (Last, First, MI) Today’s Date

Mailing Address City State Zip

Second Address (if applicable) City State Zip

Social Security Number Date of Birth Gender □ Male □ Female

Marital Status □ Single □ Married □ Divorced □ Widowed □ Separated □ Partner □ Other

Current Home Phone □ Preferred

( )

Cell Phone □ Preferred

( )

Work/Other Phone □ Preferred

( )

Email Address

Employment Status □ Full Time □ Part Time □ Not Employed□ Retired □ Student

Employer Name Employer Address & Phone

Race □ Asian □ Black/African American □ Caucasian □ Hispanic □ Native American/Alaskan Native□ Native Hawaiian/Pacific Islander □ Multi-Racial □ Unknown/Refused

Ethnicity □ Latino/Hispanic □ Non-Latino/Non-Hispanic □ Unknown/Refused

Preferred Language □ English□ Spanish □ Other ____________________

Referring Physician’s Name Primary Care Physician’s Name (Check if same as Referring Physician □)

Local Pharmacy Name and Specific Location: Mail Order Pharmacy:

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Is patient responsible party/guarantor? □Yes □No (If you are over the age of 18 and not in the care of an institution you are the guarantor as you are the person financially responsible for any charges you may incur during your visit) Name Address City/State/Zip Relationship to Patient

Home Phone □ Preferred

( )

Cell Phone □ Preferred

( )

Social Security Number

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Name Home Phone □ Preferred

( )

Cell Phone □ Preferred

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Address City/State/Zip Relationship to Patient

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Primary Insurance Company Policy # Group#

Patient’s Relationship to Insured

□ Self □ Spouse □ Child □ Other_______________________________________

Subscriber’s Full Name (If other than patient) Subscriber’s Date of Birth

Subscriber’s Social Security # Gender □ Male □ Female

Subscriber’s Employer name (if self-employed, company name)

Secondary Insurance Company Policy # Group#

Patient’s Relationship to Insured

□ Self □ Spouse □ Child □ Other_______________________________________

Subscriber’s Full Name (If other than patient) Subscriber’s Date of Birth

Subscriber’s Social Security # Gender □ Male □ Female

Subscriber’s Employer Name (if self-employed, company name)

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Is this visit the result of an accident?

□ Yes □ No

□ Employment□ Automobile □ Other

Date of Accident: (mm/dd/yyyy) Claim No.

Claim Adjuster / Contact Name Phone No.

( )

Insurance Name

Insurance Address City State Zip Phone No.

( )

By signing below, I acknowledge that the information I provided is correct to the best of my knowledge.

Patient Signature: ___________________________________________________________________________ Date: ______/______/______

Guarantor Signature: ________________________________________________________________________ Date: ______/______/______

How did you hear about us?

□ TV □ Internet □ Radio □ Other □ Friend/Family □ Newspaper □ Physician Referral

RELEASE OF INFORMATION

I hereby authorize IRMC-Physician Practices to use and disclose my health information for all purposes necessary for treatment, payment and health care operations, including but not limited to release of my information requested by my insurance company (or carrier) and any information necessary for treatment purposes.

Patient Signature: ______________________________________________________________________ Date: ______/______/______

ASSIGNMENT OF INSURANCE

I hereby authorize my insurance benefits to be paid directly to Indian River Health Services; I understand I am financially responsible for non-covered services. I authorize the release of any medical or other information necessary to process insurance claims on my behalf.

Patient Signature: _______________________________________________________________________ Date: ______/______/______

FINANCIAL LIABILITY

I have been provided a copy of the IRMC-Physician Practices financial policies and agree to the specified terms. I hereby agree to pay all charges due (or become due) to IRMC-Physician Practices for care and treatment, including co-payments and deductibles provided under my plan. Benefits, if any, paid by a third party will be credited on account. I understand that I will be responsible for charges if any of the following apply:

My health plan requires prior authorization or referral by a Primary Care Physician (PCP) before receiving services at IRMC Physician Network and I have not obtained such an authorization or referral or I receive services in excess of such authorization or referral, and/or

My health plan determines that the services I received at IRMC-Physician Practices are not medically necessary and/ or not covered by my insurance plan, and/or

My health plan coverage has lapsed or expired at the time I receive services at IRMC Physician Practices, and/or

I have chosen not to use my health plan coverage

Patient Signature: _______________________________________________________________________ Date: _____/______/______

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

We keep a record of the health care services we provide you. We will not disclose your record to others unless you direct us or unless the law authorized or compels us to do so. You may see your records or get more information about them by contacting IRMC Medical Records Department.

Our Notice of Privacy Practices describes in greater detail how your health information may be used and disclosed, and how you can access your information.

By my signature below I acknowledge receipt of the Notice of Privacy Practices.

Patient Signature: _______________________________________________________________________ Date: ______/______/______

MEDICARE PATIENTS ONLY PLEASE ANSWER QUESTIONS BELOW

Dear Medicare Patient:

As a direct result of mandated Medicare Secondary Payer (MSP) regulations, we are required to gather the following information to determine if Medicare is your primary insurance.

1. Is the Illness/injury due to an automobile accident, liability accident, or Workers’ Compensation? □ Yes □ No2. Is the illness covered by the Black Lung Program or Veterans Administration? □ Yes □ No3. If under 65, are you a renal dialysis patient in your first 30 months of Medicare entitlement? □ Yes □ No4a. If under age 65, is your Medicare coverage due to disability? □ Yes □ No4b. Is patient covered by a large group health plan through patient’s employer or Spouse’s current employer? □ Yes □ No5. If 65 and over is patient covered by Employer Group Health Plan through patient’s or Spouse’s current employer? □ Yes □ No

Patient Signature: _______________________________________________________________________ Date: ______/______/______

IRMC-PHYSCIAN PRACTICES

VERBAL AUTHORIZATION

TO DISCUSS HEALTH AND MEDICAL INFORMATION

PATIENT NAME: ______________________________________ DATE OF BIRTH: __________________

PARENT OR LEGAL GUARDIAN: __________________________________________________________

If I am not present, I authorize IRMC Physician Practices and staff to disclose my

relevant health information with the family and/or friends named below.

I decline to name family members and/or friends who my providers and staff may

discuss my health information with at this time. However, I understand that I can

always verbally authorize providers and staff to discuss health information with

family members and/or friends or I may complete form at a later date.

Name: _________________________________ Relationship: _____________ Phone#:_____________

Name: _________________________________ Relationship: _____________ Phone#:_____________

Name: _________________________________ Relationship: _____________ Phone#:_____________

Name: _________________________________ Relationship: _____________ Phone#:_____________

I understand that this authorization is valid and in effect until such time as I withdraw it in writing

or in person, or one year following date of signature.

I understand that I can revoke, update, or change this verbal authorization at any time in writing. The

termination to verbally release health and medical information is effective on the date the physician

office receives it. It does not apply to any information released prior to the date of receipt of the

written termination.

________________________________ ________________________________ ________________ Signature of patient or legal representative/guardian Authority or relationship of representative Date

(Attach copy of documentation of authority)

Date: ____________

Patient Name: ___________________________________________ DOB: _______________

Past Medical History (include all medical problems and/or surgeries)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Medications with Dosages (include over the counter and those that you take occasionally as

needed)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Allergies: (please include type of reaction)

______________________________________________________________________________

______________________________________________________________________________

Social History:

Tobacco Use :( if ever smoked; please indicate how many years of use total, how many cigarettes

per day on average): ________________. If you have quit, how long ago? ______________

Alcohol Use: ___________________ Type of beverage: ___________________________

Frequency:____________________ Average per day:_____________________________

Family History: Parents and siblings. Please indicate ages, whether living or deceased and

significant health problems.

____________________________________________________________________________

____________________________________________________________________________

Health Maintenance:

Pap Smear: Date of Most recent test: _____________ Normal ____ Abnormal ____

Mammogram: Date of Most recent test: _____________ Normal ____ Abnormal ____

Colonoscopy: Date of Most recent test: _____________ Normal ____ Abnormal ____

Bone Density: Date of Most recent test: _____________ Normal ____ Abnormal ____

Cholesterol: Date of Most recent test: _____________ Normal ____ Abnormal ____

PSA: Date of Most recent test: _____________ Normal ____ Abnormal ____

Vaccines: Last Pneumonia: ________________________

Last Tetanus: ________________________

Last Influenza: _________________________

Please list any specialists you currently see (Cardiologist, Neurologist, etc.)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Patient Name_______________________________________________________DOB:__________________

General Weight Gain: Now/Previously

Loss of appetite: Now/Previously Increased Thirst: Now/Previously

Weight Loss: Now/Previously Fatigue: Now/Previously

Loss of Sleep: Now/Previously Night Sweats: Now/Previously

Skin Skin problems: Now/Previously Discolorations: Now/Previously Bruise easily: Now/Previously Sores: Now/Previously

Skin rashes: Now/Previously Change in moles: Now/Previously Itching: Now/Previously Change in skin color: Now/Previously

Slow Healing: Now/Previously Scars: Now/Previously Skin cancer: Now/Previously

Neurological Lightheaded: Now/Previously Disorientation: Now/Previously Concussion: Now/Previously Headaches: Now/Previously

Tremors: Now/Previously

Dizzy: Now/Previously Weakness: Now/Previously Numbness: Now/Previously Disk problem: Now/Previously Seizures: Now/Previously

Fainting: Now/Previously Memory Loss: Now/Previously Tingling: Now/Previously Difficulty speaking: Now/Previously

Eyes, Ears, Nose and Throat Vision problems: Now/Previously Blurred vision: Now/Previously Nosebleeds: Now/Previously Runny nose: Now/Previously

Ear pain: Now/Previously Hearing Loss: Now/Previously Ear noises: Now/Previously Frequent Sinus trouble: Now/Previously

Sore throat: Now/Previously Mouth sores: Now/Previously Hoarseness: Now/Previously

Respiratory Coughing: Now/Previously Asthma: Now/Previously Lung Cancer: Now/Previously

Pneumonia: Now/Previously Tuberculosis: Now/Previously Coughing up blood: Now/Previously

Bronchitis: Now/Previously Difficulty breathing: Now/Previously

Cardiovascular Chest Pain: Now/Previously Shortness of Breath: Now/Previously Irregular heartbeat: Now/Previously

Chest Pressure: Now/Previously Swelling ankles: Now/Previously Murmurs: Now/Previously

High Blood Pressure: Now/Previously Low Blood Pressure: Now/Previously High Cholesterol Level: Now/Previously High Triglycerides: Now/Previously

Gastrointestinal Abdominal Pain: Now/Previously Diarrhea: Now/Previously

Constipation: Now/Previously Mucus in stool: Now/Previously

Blood in the Stool: Now/Previously Heartburn: Now/Previously

Genitourinary Incontinence: Now/Previously Blood in Urine: Now/Previously

Frequency: Now/PreviouslySexual difficulty: Now/Previously

Painful urination: Now/Previously Loss of libido: Now/Previously

Hematologic Anemia: Now/Previously Bleeding disorder: Now/Previously

Musculoskeletal Joint pain: Now/Previously Gout: Now/Previously Scoliosis: Now/Previously Birth trauma: Now/Previously

Head injury: Now/Previously Back pain: Now/Previously Bone Spurs: Now/Previously Broken bones: Now/Previously

Neck pain: Now/Previously Osteoporosis: Now/Previously Muscle weakness: Now/Previously Compression fracture: Now/Previously

Allergic/Immunologic Allergies: Now/Previously Fever: Now/Previously

Hay fever: Now/Previously HIV/AIDS: Now/Previously

Catch colds easily: Now/Previously

Women Only Hysterectomy: Now/Previously Abnormal PAP: Now/Previously Vaginal discharge: Now/Previously

Breast lumps: Now/Previously Hot flashes: Now/Previously

Irregular periods: Now/Previously Menstrual cramps: Now/Previously Nipple discharge: Now/Previously

Men Only Prostate trouble: Now/Previously Difficulty starting urine: Now/Previously

Dribbling urine: Now/Previously Nighttime urination: Now/Previously Burning on urination: Now/Previously

Review of Systems (Circle if you currently have, or previously had, leave blank if never had)

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Indian River Medical Center, Vero Beach FL 32960 Authorization for Release of Information

Patient Information

Patient Name__________________________________ Date of Birth________ Social Security Number______________

Address_________________________________ City_________________________ State _____ Zip______________

Phone_______________________ Medical Record Number (if known)______________________________

Disclosure From/To

I hereby authorize IRMC Other Healthcare Provider ____________________________________ To disclose to: Recipient Information

Recipient Name___________________________________________

Recipient Address_________________________________City___________________State_____Zip______________

Phone___________________ Special Instructions: ______________________________________________________

Authorization Time Frame and Purpose of Disclosure This authorization expires in 6 months unless otherwise specified.

Enter expiration date _________________________ or event date______________________________.

The purpose of the disclosure is: Continued Care/Dr.____________________________ Reimbursement

Personal Records Disability

Legal Purpose School

Other (Describe):

Description of Information to be Disclosed

Is this request for psychotherapy notes? Yes, then this is the only item you may request on this authorization. You

must submit another authorization for other items below. No, then you may check as many items below as you need:

All PHI in medical record

Date(s): Operative report Date(s): ED records Date(s):

History and Physical Cath Lab Labor and Delivery records

Physician orders Physician progress notes

OB nursing assessment

Intake/output Rhythm strips Postpartum flowsheet

Discharge summary Nursing admission/notes

Billing records

Medication sheets Immunization records Therapy notes (PT/OT/Speech)

Cardiology reports Transfer forms Pathology reports

Lab specimen Other: Other:

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Indian River Medical Center, Vero Beach FL 32960 Authorization for Release of Information

Lab reports (specify dates)

Xray/imaging reports (specify dates)

Consultation reports by

I acknowledge and hereby consent to such that the released information may contain sexually transmitted diseases, alcohol and drug abuse, psychiatric or mental health services, HIV testing, HIV results or AIDS information. ____(Initials)

I understand that:

I may refuse to sign this authorization and that it is strictly voluntary.

If I do not sign this form, my health care and the payment for my health care will not be affected unless stated otherwise (see Signature section).

I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation or when the law provides for my insurer to have the right to contest a claim under my policy. Further details can be found in the Notice of Privacy Practices.

If the requestor or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be redisclosed.

I may see and obtain a copy of the information described on this form for a copy fee if I ask for it.

I get a copy of this form after I sign it if requested. ----------------------------------------------------------------------------------------------------------------------------- -------------------------------------

Is the requestor of this PHI another health plan or health care provider? Yes No If yes, the health plan or health care provider must complete the following:

Will the requestor receive financial or in-kind compensation in exchange for using or disclosing this information?

No Yes If yes, describe: _____________________________________________________________

What is the purpose or use of this disclosure? ____________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------------------------- ----------

SIGNATURE By signing below, I have read the information on this form and authorize the disclosure of the protected health information as stated.

_____________________________________________________________ (Patient/Guardian/Patient Representative) (Signature/Date)

_____________________________________________________________ (Patient/Guardian/Patient Representative) (Print Name/Date)

______________________________________________________________ (Guardian/Patient Representative) (Relationship to Patient)

------------------------------------------------------------------------------------------------------------------------ --------- Note: The identity of the requestor has been validated either with a government issued picture ID, such as a driver’s

license or a passport, or comparison of signatures documented in the PHI records. Yes No (If no, describe Type

of ID________________________________________________

MEDICARE SECONDARY PAYOR (MSP) QUESTIONNAIRE

Patient Name:____________________________________ Date of Birth_______________________

Physician: _______________________________________ Medical Record #:__________________

I AM ENTITLED TO MEDICARE BENEFITS:

[ ] NO - RETURN FORM TO THE FRONT DESK

[ ] YES - PROCEED TO SECTION I.

SECTION I Select the ONE statement that is true for you:

[ ] I a o er a d arried… Proceed to section II

[ ] I a o er a d ot arried i ludes ido ed … Proceed to section III

[ ] I a u der , Disa led a d urre tly e ployed… Proceed to section IV

[ ] I a u der , Disa led a d u e ployed… Disability Date: _____________________ IV Proceed to section

SECTION II Select the one statement that is true for you:

[ ] My spouse and I are both fully retired

The date of my retirement: _________________________

The date of y spouse’s retire e t: __________________ …Proceed to section V

[ ] I work full or part-time (my spouse is retired) for a company with:

[ ] LESS tha 20 e ployees… Proceed to section V

[ ] MORE tha 20 e ployees… Proceed to section IV

[ ] My spouse works full or part-time (I am retired) for a company with:

[ ] LESS tha 20 e ployees… Proceed to section V

[ ] MORE tha 20 e ployees… Proceed to section IV

SECTION III Select the one statement that is true for you:

[ ] I a fully retired… The date of y retire e t: _____________________ ….Proceed to section V

[ ] I work full or part-time for a company with:

[ ] LESS tha 20 e ployees… Proceed to section V

[ ] MORE tha 20 e ployees… Proceed to section IV

SECTION IV Select the one statement that is true for you: (This does not apply to supplemental plans or employer

plans offered during retirement.)

I have health care coverage through my employer. [ ] NO [ ] YES

I have health care coverage through someone else. [ ] NO [ ] YES

IF YES, list name of guardian and relationship:__________________________________________

Proceed to Section V

Patient Name: ___________________________ Date of Birth_____________________

SECTION V Is this visit related to an injury due to a fall?

[ ] YES - Did the a ide t o ur i … [ ] your ho e [ ] pu li lo atio [ ] other Date of Accident:___________________

OR

Is this visit related to an illness/injury due to an automobile accident?

[ ] YES - Date of Accident:_____________________________

RETURN TO FRONT DESK AND PRESENT YOUR AUTOMOBILE INSURANCE CARD.

[ ] NO Proceed to Section VI

SECTION VI Indicate which statements apply to you.

[ ] I a e titled to Worker’s Co pe satio for this ser i e. [ ] I am entitled to Black Lung benefits.

[ ] I am entitled VA benefits.

[ ] I am entitled ESRD benefits.

[ ] I am entitled COBRA benefits.

[ ] I a e titled to other Federal e efits. UMWA, Go ’t resear h progra s, Hospi e Please Explain: _____________________________________________________________________

__________________________________________________________________

Patient Signature ________________________________ Date ________________

Staff Signature ________________________________ Date ________________

What does “Provider Based designation mean?

This is a Medicare status for hospitals and clinics that comply with specific Medicare regulations. Medicare has determined that IRMC has met these regulations and has now been designated as such. This status requires that IRMC bill Medicare in two (2) parts.

What does “Hospital Services” mean on my bill? I didn’t go to the hospital for my care.

Medicare allows hospitals to bill for both the physician and hospital outpatient services, in two separate charges, when a patient is seen in a physician office owned by a hospital. Most hospitals have opted to utilize this approach to billing.

Your billing statement includes two separate charges for each visit – one for the physician’s services (Part B) and another for the hospital outpatient facility and technical services (Part A). The hospital outpatient facility and technical services charge will be clearly defined on your bill under the description “Hospital Services.” We understand this may seem complicated and apologize in advance for any confusion this may cause.

Will Medicare cover this?

Most Medicare patients will be covered by their supplemental insurance and will not have to pay more out-of-pocket. Medicare patients without supplemental insurance will pay a small amount. Patients with health insurance will need to check with their insurance provider to determine what will be covered by their insurance plan. Cost will vary based on the type of benefit plan you have. Most patients will not have to pay any additional dollars out-of-pocket.

Estimate of your financial responsibility Medicare requires that we provide you with an estimate of your Part A and Part B coinsurance amounts. These amounts will vary based on the type and number of services received.

Estimate of Coinsurance Charges Part A Part B Office Visit $10 to $34 $2 to $37

Radiology $8 to $16 NA

Cardiovascular Diagnostics $10 to $170 $10 to $35

Pulmonary Test $8 to $43 $2 to $6

*Certain tests and procedures have higher coinsurance amounts due to their complexity.

Why does the Medicare Secondary Payor (MSP) Questionnaire need to be completed?

As a participating Medicare provider IRMC is required to screen Medicare patients according to the Medicare Secondary Payor (MSP) rules. At each visit, business services representatives will ask you the MSP questions. These questions will help to confirm if Medicare or another payer should process the claim as primary.

What type of questions should I ask my health insurance company?

Ask your health insurance company whether it covers facility charges or provider-based billing. If it does, ask what percentage of the charge is covered.

Please contact our Patient Financial Services office at 772-794-5611 with any questions you may have.

_____________________________ _________________ Patient Signature Date

Provider Based Billing Information

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOUCAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

THIS NOTICE APPLIES TO SERVICES FURNISHED TO YOU BY INDIAN RIVER MEDICAL CENTER AND ITS SUBSIDIARIES(COLLECTIVELY “INDIAN RIVER MEDICAL CENTER”), ITS EMPLOYED AND NON-EMPLOYED STAFF, VOLUNTEERS ANDTRAINEES, AS WELL AS THE PHYSICIANS AND OTHER HEALTHCARE PRACTITIONERS WHO PROVIDE SERVICES AS ANINPATIENT OR OUTPATIENT OR ANY OTHER SERVICES PROVIDED TO YOU IN A HOSPITAL-AFFILIATED PROGRAMINVOLVING THE USE OR DISCLOSURE OF YOUR HEALTH INFORMATION. THIS NOTICE ALSO DESCRIBES HOWAUTHORIZED HEALTH CARE PROVIDERS MAY USE AND DISCLOSE YOUR HEALTH INFORMATION ELECTRONICALLYTHROUGH THE “IRMC-HEALTHY ME” HEALTH INFORMATION EXCHANGE (HIE). YOU CAN GET ADDITIONAL INFOR-MATION ABOUT THE HIE FROM YOUR PARTICIPATING PROVIDER’S REGISTRAR OR RECEPTIONIST, OR BY VISITINGWWW.IRMC-HEALTHYME.COM OR WWW.IRMCHEALTHYME.COM.

Understanding Your Health Record/InformationEach time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-relatedinformation. This information, often referred to as your health or medical record, may serve as:

• A basis for planning your care/treatment;• A means of communication among the health professionals who contribute to your care;• A legal document describing the care you received;• A means by which you or a third party payer can verify that services billed were actually provided;• A tool in educating health professionals;• A source of data for medical research;• A source of information for public health officials charged with improving the health of the nation;• A source of data for facility planning and marketing; and• A tool with which we can assess and improve the care we render and the outcomes we achieve.

Our ResponsibilitiesWe are required by law to maintain the privacy of your health information, to provide you with this notice of our legal duties andprivacy practices with respect to your health information, and to notify you if there is a breach of your unsecured health information.We will abide by the terms of this notice.

Permissible Uses and Disclosures Without Your Written Authorization By law, we are allowed to use and disclose your health information for most purposes related to your medical treatment (“treatment”), the payment for your medical treatment (‘payment”), and our healthcare operations (“operations”). The followingcategories describe examples of the way we use and disclose health information:

For Treatment:We may use health information about you to provide you treatment or services. We may disclose health informationabout you to doctors, nurses, technicians, medical students, or other facility personnel who are involved in taking care of you at thefacility. For example: a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Different departments of the facility also may share health information about you in order to coordinate the different things you may need, such as prescriptions, lab work, meals, and x-rays. We may also provide your physician or a subsequenthealthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from this facility.

For Payment:We may use and disclose health information about your treatment and services to bill and collect payment from you,your insurance company or a third party payer. For example, we may need to give your insurance company information about yoursurgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going toreceive to determine whether your plan will cover it.

For Health Care Operations:Members of the medical staff and/or quality improvement team may use information in your healthrecord to assess the care and outcomes in your case and others like it and for conducting training programs or reviewing compe-tence of health care professionals. The results will then be used to continually improve the quality of care for all patients we serve.For example, we may combine health information about many patients to evaluate the need for new services or treatment. We maydisclose information to doctors, nurses, and other students for educational purposes. And we may combine health information wehave with that of other facilities to see where we can make improvements. We will remove information that identifies you from thisset of health information to protect your privacy.

INDIAN RIVER MEDICAL CENTERNOTICE OF PRIVACY PRACTICES

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Business Associates: There are some services provided in our organization through contracts with business associates. Examplesinclude physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our businessassociates so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, business associates are required by federal law to appropriately safeguard your information.

Facility Directory: Unless you notify us that you object, we may include certain limited information about you in the facility directory while you are a patient at the facility. The information may include your name, location in the facility, your general condition (e.g., good, fair) and your religious affiliation. This information may be provided to members of the clergy and, except forreligious affiliation, to other people who ask for you by name. If you would like to opt out of being in the facility directory pleaserequest the Opt-Out Form from the admission staff or Facility Privacy Official. Even if you ask us to keep your information out ofthe directory, we may share your information for disaster-relief efforts or in a declared emergency situation.

Individuals Involved in Your Care or Payment for Your Care: Health professionals, using their professional judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, your health information that isrelevant to that person’s involvement in your care or payment related to your care. In addition, we may disclose information aboutyou to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Research:We may disclose information to researchers when an institutional review board that has reviewed the research proposaland established protocols to ensure the privacy of your health information has approved their research and granted a waiver of theauthorization requirement.

Organized Health Care Arrangement: This facility and its medical staff members have organized and are presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment, payment and health care operations.Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as itmay affect treatment at the time.

As required by law, we may also use and disclose health information for the following types of entities including, but not limited to:

Funeral Directors: We may disclose health information to funeral directors, coroners and medical examiners consistent with applicable law to assist them in carrying out their duties.

Organ Procurement Organizations: Consistent with applicable law, we may disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Food and Drug Administration (FDA):We may disclose to the FDA health information relative to adverse events with respect tofood, supplements, product and product defects or post-marketing surveillance information to enable product recalls, repairs orreplacement.

Workers Compensation:We may disclose health information to the extent authorized by and to the extent necessary to complywith laws relating to workers compensation or other similar programs established by law.

Specialized Government Functions: If you are in the military or a veteran, we will disclose your health information as required bymilitary command authorities or as required by law. We may disclose health information to authorized federal official for nationalsecurity purposes and intelligence activities.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose your health information to theinstitution or agents thereof, as necessary for your health, and the health and safety of other individuals.

Public Health: We may disclose health information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury, or disability.• To report births and deaths.• To notify a person who may have been exposed to a communicable disease or may otherwise be at risk for contracting orspreading a disease or condition.

• For population based activities relating to improving health or reducing health care costs.

Victims of Abuse, Neglect or Domestic Violence: Your health information may be disclosed as authorized by law if there is a reasonable belief that you are a victim of abuse, neglect, exploitation, or domestic violence. We'll only make this disclosure if youagree or when required or authorized by law.

Health oversight activities: We may disclose medical information to a health oversight agency for activities authorized by law.These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for thegovernment to monitor the healthcare system, government programs, and compliance with civil rights laws.

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Patient Safety Organization: Indian River Memorial Hospital d/b/a Indian River Medical Center (IRMC) contracts with PSOFlorida.IRMC will submit to and receive patient safety work product from PSOFlorida. PSOFlorida has been formed as a component organization of the Florida Hospital Association (FHA) under the authority of the Patient Safety and Quality Improvement Act, whichwas passed by Congress in 2005. PSOFlorida’s mission is to improve the safety and quality of healthcare delivery thorough the application of science and implementation of best-practice evidence with the objective of preventing patient injury or death.

Law Enforcement/Legal Proceedings:We may disclose health information for law enforcement purposes or legal proceedings asrequired by law or in response to a valid subpoena or court order.

Health Information Exchange (HIE):We and other healthcare providers participate in a Health Information Exchange to facilitatethe secure exchange of your electronic health information between and among several health care providers or other health careentities for your treatment, payment, or other healthcare operations purposes. This means we may share information we obtain orcreate about you with outside entities (such as hospitals, doctors offices, pharmacies, or insurance companies) or we may receiveinformation they create or obtain about you (such as medication history, medical history, or insurance information) so each of us canprovide better treatment and coordination of your healthcare services.

Fundraising: We may contact you as part of a fundraising effort unless you elect not to receive any such communications. We mayuse certain information (name, address, phone number, email, date of birth, gender, health insurance, service dates, department ofservice, and outcome information) to contact you for the purpose of fundraising. You have the right to “opt out” of receiving such com-munication and your decision to opt out will have no impact on your treatment or payment rights. To opt out, please call 772.226.4978to leave your name, address, phone number, and date of birth so we may ensure you are removed from our communications.

A School: We may disclose information if you are a student or prospective student if the information is limited to proof of immu-nizations, the school is required by State or other law to have such proof prior to admitting you, and the Hospital obtains and documents the agreement to the disclosure from either a parent, guardian, or other person acting in loco parentis of the individual(if an unemancipated minor) or from you (if an adult or emancipated minor).

Other Permitted Disclosures:When contacting you, primarily regarding appointment reminders and billing/collection efforts, wemay leave messages on your answering machine/voice mail.

In the event that one or more of Indian River Medical Center entities is sold or merged with another organization, your health information will become the property of the new owner.

We may disclose your health information as required or permitted by the privacy regulations promulgated pursuant to the HealthInsurance Portability and Accountability Act, as amended and interpreted from time to time.

State-Specific Requirements: Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs. Some states have separate privacy laws that may apply additional legal requirements. If the state privacy laws are more stringent than federal privacy laws, the state law preempts the federal law.

Uses and Disclosures That Require Your Written AuthorizationOther uses and disclosures not described in this notice will be made only with your written authorization. Your written authorizationis required for any disclosure of psychotherapy notes, except to carry out the treatment, payment, or health care operations allowedby law. Your written authorization is required for any use or disclosure of your health information for marketing, except if the communication is a face-to-face communication made by the Hospital to you, or is a promotional gift of a nominal value provided bythe Hospital. If the marketing involves financial remuneration to the Hospital from a third party, the authorization will state thatremuneration is involved. The Hospital will obtain your written authorization for any disclosure of your health information which isa sale of your health information. This authorization will state that the disclosure will result in remuneration to the Hospital. You mayrevoke your authorization at any time, provided the revocation is in writing.

Your Health Information RightsAlthough your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the Right to:

Inspect and Copy Your Health Information:You have the right to inspect and obtain a copy of the health information that may beused to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the facility will reviewyour request and the denial. The person conducting the review will not be the person who denied your request. We will comply withthe outcome of the review. If you request a copy of your information for your own personal use, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. You may request to receive an electronic copy of your health information. If it is readily producible in such form, you will receive it as requested; otherwise, the Hospital will provide the readableelectronic form and format that is producible and you agree to receipt in this format. If you direct us to send a copy of your healthinformation directly to another person, you will be asked to request this in writing, signed by you, and clearly identify the designatedperson and where to send the copy of your health information

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Amend Your Health Information Records: If you feel that health information we have about you is incorrect or incomplete, youmay ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or forthe facility. Any request for an amendment must be sent in writing to the Facility Privacy Official. We may deny your request for anamendment and if this occurs, you will be notified of the reason for the denial.

Receive An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of certain disclosures we make of your health information for purposes other than treatment, payment or health care operations where anauthorization was not required.

Receive Restrictions:You have the right to request a restriction or limitation on the health information we use or disclose aboutyou for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. Any request for a restriction must be sentin writing to the Facility Privacy Official. We are required to agree to your request only if 1) except as otherwise required by law, thedisclosure is to your health plan and the purpose is related to payment or health care operations (and not treatment purposes), and2) your information pertains solely to health care services for which you have paid in full. For other requests, we are not requiredto agree. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

Health Information Exchange:With regard to the IRMC-Healthy Me HIE only, if you do not wish to allow independent doctors,nurses, and other clinicians involved in your care to electronically share your health information through the IRMC-Healthy MeHIE,you may do the following: do not sign in to the IRMC-Healthy Me HIE; if you have already signed in and wish to “opt out,” pleasenotify us in writing of your opt out preference. You may send your opt out written request via mail to Mindy Serafin, Privacy Official,Indian River Medical Center, 1000 36th Street, Vero Beach FL 32960, or fax your written request to 772.562.5628 Attention PrivacyOfficial Mindy Serafin. Opting out of the HIE will not impact how your information is accessed and released in accordance with thisNotice and the law

Request Confidential Communications:You have the right to request that we communicate with you about medical matters in acertain way or at a certain location. For example, you may ask that we contact you at work instead of your home. The facility willgrant reasonable requests for confidential communications at alternative locations and/or via alternative means only if the requestis submitted in writing and the written request includes a mailing address where the individual will receive bills for services renderedby the facility and related correspondence regarding payment for services. Please realize, we reserve the right to contact you by othermeans and at other locations if you fail to respond to any communication from us that requires a response. We will notify you inaccordance with your original request prior to attempting to contact you by other means or at another location.

Receive A Paper Copy of This Notice:You have the right to a paper copy of this notice. You may ask us to give you a copy of thisnotice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To exercise any of your rights, please obtain the required forms from the Privacy Official and submit your request in writing.

Other Uses of Your Health Information Other uses and disclosures of your health information not covered by this notice or the laws that apply to us will be made only withyour written permission/authorization. If you provide us authorization to use or disclose health information about you, you mayrevoke that authorization, in writing, at any time. If you revoke your permission, we will no longer use or disclose health informationabout you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures wehave already made with your permission, and that we are required to retain our records of the care that we provided to you.

Changes to this NoticeWe reserve the right to change this notice and the revised or changed notice will be effective for information we already have aboutyou as well as any information we receive in the future. The current notice will be posted in the facility and on our website andincludes the effective date. If this notice is changed, the new notice will be posted in the facility and on our website and will includeits effective date, and you will be provided with a copy of the Notice when it changes.

For More Information or to Report a Problem If you have questions regarding our privacy practice or would like additional information, you may contact the Privacy Official at772.567.4311, ext. 1124. If you believe your privacy rights have been violated, you may file a complaint with the Privacy Official atIndian River Medical Center. You may also file a complaint with the Secretary of the Department of Health and Human Services athttp://www.hhs.gov/ocr/office/index.html. There will be no retaliation against you for filing a complaint.

Facility Privacy OfficialIndian River Medical Center, Mindy Serafin Telephone: (772) 567-4311 ext. 1124

31-1811-4 4/03Effective Date of Notice 04/14/03Revised 01/09, 05/12, 09/12, 09/13

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1000 36th Street Vero Beach, FL 32960 Phone: 772.794.5611

Fax: 772.794.1450

Thank you for choosing IRMC-Physician Practices for your medical care. We appreciate that you have entrusted us with your healthcare needs. We are committed to providing you with the best patient care available.

Because healthcare benefits and coverage options have become increasingly complex, we have developed this financial policy to help you understand your responsibilities as a patient. We will do our best to assist you with understanding your proposed treatment and in answering questions related to submitting your insurance claim forreimbursement.

Your health insurance policy is a contract between you and your health insurance company. Please note it is your responsibility to know if your insurance requires referrals, pre-certifications, pre-authorizations, limits on outpatient charges, and any requirements for specific physicians, labs and/or hospitals to use. You should beknowledgeable of any deductibles, copayments, and/or coinsurance or other out-of-pocket expenses for your care.

If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details about your benefits.

Refunds

A refund is issued when an overpayment has been identified. If you feel a refund is due, please contact our billing office at772.794.5611.

Failure to Pay

If you do not pay your bill, your account may be sent to an outside collection agency. If your account is sent to a collection agency, you will need to contact them directly to settle your balances.

Policy and Fee Changes

These policies and fees are subject to change. We will keep you informed of any modifications.

We realize medical care isan unexpected expense. If you have concerns about your ability to pay, you can contact us for help in managing your account. If you have questions about these policies, please contact our billing office at 772.794.5611.

IRMC-Physician Practices Financial Policies

IRMC-Physician Practices

Provider-Based Billing

IRMC-Physician Practices are departments or provider-based clinics of the hospital. Under Medicare, if a physician office meets specific regulations the hospital can classify the physician practice as a provider-based clinic. Because of this, you will receive two Medicare Summary notices, one from Medicare Part A and one from Medicare Part B. On your statement, you will see both a provider charge and a clinic charge. The clinic charge, or Medicare Part A services, will cover expenses such as nursing and support staff, as well as any medical or technical supplies or equipment and the use of the room. Services, treatments or procedures provided by your doctor or practitioner will be classified as provider charges under Medicare Part B.

Insurance Coverage

Please provide us with your current insurance plan information at the time of each visit and notify us of any changes. We will request a copy of your insurance card to copy or scan and keep on file for our records.

Our doctors belong to many insurance plans but participation differs by doctor. Before your appointment, please be sure your doctor is in-network and the services are covered under your plan. If your doctor is out-of-network, you will be billed for the cost of care. Refer to our out-of-network policy below for more details.

Please be aware of and provide required referrals or authorizations prior to yourappointment. If this information is not available, you will be responsible for the cost of the care. When in doubt, contact your plan directly for clarification.

Financial Policies

Address Change

It is important that IRMC-Physician Practices hasyour correct address information on file. Pleaseadvise us if there is any change to your address, telephone or other contact information.

Co-payments/Co-insurances/Deductibles

You are expected to pay your co-payment and anyco-insurance and/or deductible amounts, if known, at the time of service.

Payments

Payment is due at the time services are provided orupon receipt of a statement from our billing office.

We accept payment in the form of cash, check, money order or credit card (American Express, MasterCard, Visa and Discover). Returned checks are subject to a fee of $25. We do not accept traveler's checks.

Non-Medical Fees

Additional fees may apply to the following:• Returned checks• Copying of medical records• Completion of disability or other forms

Missed Appointments

As a courtesy to other patients and our physicians, please provide 24-hour advance notice if you areunable to keep yourappointment. Procedures andsurgeries vary by practice, and will be discussed attime of scheduling.

Out-of-Network Providers

If the doctor is not on your insurance plan, the following rules apply:

•Full payment is due at the time of servicefor routine visits.

•Payment expected on the date of servicemay be an estimate of your total charges.

•You will be quoted an estimated feebefore services/procedures are performed.

•After your appointment, we will submit a claim to your plan for services performed.

•Depending on your plan, payment may besent to you. If you receive this payment, youmust reimburse Indian River Health Services immediately.

Non-Covered Services

Medicare PatientsMedicare may not cover some services yourdoctor recommends. You will be informedahead of time and given an AdvancedBeneficiary Notice (ABN) to read and sign. The ABN will help you decide whether youwant to receive services, knowing you areresponsible for payment. You must read theABN carefully before signing.

Commercial InsuranceServices not covered by your plan are yourresponsibility and must be paidin full at thetime of service or upon receiving a bill.

Provider-Based Billing

IRMC-Physician Practices are departments orprovider-based clinics of the hospital. UnderMedicare, if a physician office meets specificregulations the hospital can classify the physician practice as a provider-based clinic. Because of this,you will receive two Medicare Summary notices,one from Medicare Part A and one from Medicare Part B. On your statement, you will see both aprovider charge and a clinic charge. The cliniccharge, or Medicare Part A services, will coverexpenses such as nursing and support staff, as well as any medical or technical supplies or equipment and the use of the room. Services, treatments orprocedures provided by your doctor or practitionerwill be classified as provider charges underMedicare Part B.

Insurance Coverage

Please provide us with your current insurance plan information at the time of each visit and notify us of any changes. We will request a copy of yourinsurance card to copy or scan and keep on file forour records.

Our doctors belong to many insurance plans but participation differs by doctor. Before yourappointment, please be sure your doctor is in-network and the services are covered underyour plan. If your doctor is out-of-network, you will be billed for the cost of care. Refer to ourout-of-network policy below for more details.

Please be aware of and provide required referrals orauthorizations prior to yourappointment. If thisinformation is not available, you will be responsiblefor the cost of the care. When in doubt, contact your plan directly for clarification.

Financial Policies

Address Change

It is important that IRMC-Physician Practices has your correct address information on file. Please advise us if there is any change to your address, telephone or other contact information.

Co-payments/Co-insurances/Deductibles

You are expected to pay your co-payment and any co-insurance and/or deductible amounts, if known, at the time of service.

Payments

Payment is due at the time services are provided or upon receipt of a statement from our billing office.

We accept payment in the form of cash, check, money order or credit card (American Express, MasterCard, Visa and Discover). Returned checks are subject to a fee of $25. We do not accept traveler's checks.

Non-Medical Fees

Additional fees may apply to the following: • Returned checks • Copying of medical records • Completion of disability or other forms

Missed Appointments

As a courtesy to other patients and our physicians, please provide 24-hour advance notice if you are unable to keep yourappointment. Procedures and surgeries vary by practice, and will be discussed at time of scheduling.

Out-of-Network Providers

If the doctor is not on your insurance plan, the following rules apply: •Full payment is due at the time of service

for routine visits. •Payment expected on the date of service

may be an estimate of your total charges. •You will be quoted an estimated fee

before services/procedures are performed. •After your appointment, we will submit a

claim to your plan for services performed. •Depending on your plan, payment may be

sent to you. If you receive this payment, you must reimburse Indian River Health Services immediately.

Non-Covered Services

Medicare Patients Medicare may not cover some services your doctor recommends. You will be informed ahead of time and given an Advanced Beneficiary Notice (ABN) to read and sign. The ABN will help you decide whether you want to receive services, knowing you are responsible for payment. You must read the ABN carefully before signing.

Commercial Insurance Services not covered by your plan are your responsibility and must be paidin full at the time of service or upon receiving a bill.

Provider-Based Billing

IRMC-Physician Practices are departments orprovider-based clinics of the hospital. UnderMedicare, if a physician office meets specificregulations the hospital can classify the physician practice as a provider-based clinic. Because of this,you will receive two Medicare Summary notices,one from Medicare Part A and one from Medicare Part B. On your statement, you will see both aprovider charge and a clinic charge. The cliniccharge, or Medicare Part A services, will coverexpenses such as nursing and support staff, as well as any medical or technical supplies or equipment and the use of the room. Services, treatments orprocedures provided by your doctor or practitionerwill be classified as provider charges underMedicare Part B.

Insurance Coverage

Please provide us with your current insurance plan information at the time of each visit and notify us of any changes. We will request a copy of yourinsurance card to copy or scan and keep on file forour records.

Our doctors belong to many insurance plans but participation differs by doctor. Before yourappointment, please be sure your doctor is in-network and the services are covered underyour plan. If your doctor is out-of-network, you will be billed for the cost of care. Refer to ourout-of-network policy below for more details.

Please be aware of and provide required referrals orauthorizations prior to yourappointment. If thisinformation is not available, you will be responsiblefor the cost of the care. When in doubt, contact your plan directly for clarification.

Financial Policies

Address Change

It is important that IRMC-Physician Practices hasyour correct address information on file. Pleaseadvise us if there is any change to your address, telephone or other contact information.

Co-payments/Co-insurances/Deductibles

You are expected to pay your co-payment and anyco-insurance and/or deductible amounts, if known, at the time of service.

Payments

Payment is due at the time services are provided orupon receipt of a statement from our billing office.

We accept payment in the form of cash, check, money order or credit card (American Express, MasterCard, Visa and Discover). Returned checks are subject to a fee of $25. We do not accept traveler's checks.

Non-Medical Fees

Additional fees may apply to the following:• Returned checks• Copying of medical records• Completion of disability or other forms

Missed Appointments

As a courtesy to other patients and our physicians, please provide 24-hour advance notice if you areunable to keep yourappointment. Procedures andsurgeries vary by practice, and will be discussed attime of scheduling.

Out-of-Network Providers

If the doctor is not on your insurance plan, the following rules apply: •Full payment is due at the time of servicefor routine visits. •Payment expected on the date of servicemay be an estimate of your total charges. •You will be quoted an estimated feebefore services/procedures are performed. •After your appointment, we will submit aclaim to your plan for services performed. •Depending on your plan, payment may besent to you. If you receive this payment, you must reimburse Indian River Health Services immediately.

Non-Covered Services

Medicare Patients Medicare may not cover some services your doctor recommends. You will be informed ahead of time and given an Advanced Beneficiary Notice (ABN) to read and sign. The ABN will help you decide whether you want to receive services, knowing you are responsible for payment. You must read the ABN carefully before signing.

Commercial Insurance Services not covered by your plan are your responsibility and must be paidin full at the time of service or upon receiving a bill.