I voluntarily consent to receive medical and health care services at The Center for Cancer and Blood Disorders (CCBD) provided by physicians, employees and such associates, assistants, and other health care providers, as my physicians deem necessary. I understand that such services may include diagnostic procedures (such as lab and x-rays), examinations, and treatment that may include chemotherapy and/or radiation therapy and services that may assist me with receiving benefits or services from an outside agency. This consent is valid for so long as I am a patient of CCBD, including for each and all visits, unless and until revoked by me in writing.

Please be informed Texas law allows a patient to be tested for possible exposure to the Human Immunodeficiency Virus (HIV), the virus associated with AIDS, in the following situations: 1) to screen blood, blood products, organs or tissues to determine suitability for donation; 2) if another individual is accidentally exposed to a patient’s blood or body fluids, such as through a needle stick (any such test shall be conducted pursuant to CCBD’s infectious disease protocol); or 3) if a medical or surgical procedure is to be performed which could expose health care workers to the patient’s blood or body fluids. This disclosure is to inform you that you may be tested, at the expense of CCBD if any of these situations occur during your treatment period.

I understand that no warranty or guarantee has been made to me as to result or cure. I certify that this form has been fully explained to me, that I have read it or had it read to me*, and that I understand its contents.

RELEASE OF INFORMATION
I authorize CCBD and affiliated physician groups to share information about me, as necessary, to obtain services from business associates of CCBD such as: quality assessment and improvement, protocol and clinical guidelines development, outcome evaluation, training programs, credentialing, medical review, legal services, insurance services and billing services.

FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS: In consideration for receiving medical or health care services, I hereby assign my right, title, and interest in all insurance, Medicare, Medicaid, patient assistance programs, or other third-party payer benefits for medical or health care services otherwise payable to me to The Center for Cancer and Blood Disorders (CCBD). I also authorize direct payments to be made by Medicare/Medicaid and/or my insurance company patient assistance programs, or other third- party payer, up to the total amount of my medical and health care charges, to CCBD.

I agree to pay all charges for medical and health care services not covered by or which exceed the amount estimated to be paid or actually paid by Medicare/Medicaid, my insurance company, or other third-party payer and agree to make payment as requested by CCBD.

Copayments are due at time of service. However, I understand I may be responsible for additional coinsurance and/or deductibles as determined by my insurance company once they have paid my claim.

I understand that if I am not able to pay my balance in full, I am responsible for contacting CCBD’s billing office and/or financial counselors to discuss a payment schedule. If I fail to make payments as agreed upon, my account may be referred to a professional collection agency and/or attorney. I understand I will be responsible for all costs incurred, including attorney’s fees and court costs if applicable.

In the event I submit payment by check and the bank returns the check unpaid for any reason, CCBD will add $25 to my original balance.

I acknowledge that I will be asked to provide a copy of my insurance card at each visit. I understand that if I do not provide current proof of insurance, I may be treated as a self-pay. I acknowledge that I am required to provide CCBD with the correct, updated insurance information at every visit and will be responsible for any charges incurred if the information provided is not correct or updated.

I acknowledge that if CCBD does not have my card on file, or is unable to verify my eligibility for benefits, I will be treated as a self-pay patient. As a self-pay patient, payment is expected to be paid in full at the time of service.

MEDICARE PATIENTS:

• If you have switched from traditional Medicare to a Medicare replacement plan, YOU MUST ADVISE US AT THE TIME OF SERVICE and provide a copy of your new card.
• If you have switched from one Medicare replacement plan to another, YOU MUST ADVISE US AT THE TIME OF SERVICE and provide a copy of your new card.
• If you have switched primary care physicians and you are on a Medicare replacement plan, YOU MUST ADVISE US AT THE TIME OF SERVICE and provide a copy of your new card.

MEDICAID PATIENTS:

• If you have switched from one Medicaid Managed Care Plan to another, YOU MUST ADVISE US AT THE TIME OF SERVICE and provide a copy of your new card.

I certify that the information I have provided in connection with any application for payment by third-party payers, including Medicare/Medicaid, is correct and that it is my responsibility to notify CCBD of changes to my address, telephone number, primary care physician or insurance carrier.

A HIPAA Contact is a person that you authorize The Center for Cancer and Blood Disorders to release information about your medical condition. Any physicians who provide medical care to you don’t need to be listed as HIPAA contacts.

An Emergency Contact is a person that you authorize The Center for Cancer and Blood Disorders to contact in the event you have a medical emergency while being treated in our office.

You have the option to select different types of contacts. You may designate separate people to be your HIPAA or Emergency contact, but you may also designate the same person as both your HIPAA and Emergency Contact. Please indicate your designations below.

Advance directives are legal documents that allow you to convey your decisions about end-of-life care ahead of time. They provide a way for you to communicate your wishes to family, friends and health care professionals, and to avoid confusion later on. The following describes healthcare advance directives.

Directive to Physicians and Family or Surrogates (Living Will) Designed to help people communicate their wishes about medical treatment at some time in the future when they are unable to make their wishes known because of illness or injury.

Medical Power of Attorney (MPOA) Gives someone named as agent the authority to make any and all health care decisions in accordance with someone’s specified wishes, including religious and moral beliefs, when that person is no longer capable of making those decisions themselves.

Out-of-Hospital Do-Not-Resuscitate (DNR) Instructs emergency medical personnel and other health care professionals to forgo resuscitation attempts and to permit the patient to have a natural death with peace and dignity. This does NOT affect the provision of other emergency care including comfort care.