Preferred Pharmacy, Name and Address
I authorize AIMPC and SS and its affiliated Providers to view my external prescription history via the ePrescribing services. I understand that prescription history from other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and the staff and it may include prescriptions back in time for several years.
I authorize direct payment be made to above named corporation. I understand AIMPC, SS and affiliate Providers will file an Insurance claim on my behalf as a courtesy nevertheless, I am financially responsible for the charge not covered by my insurance company. I also understand that if my account is not paid by myself or the insurance company after 90 days for the date of service, it will be turned over to an independent collection agency. In the event of default, I agree to pay any collection cost and/or attorney fees, as be required, to collect charges incurred. I agree to pay interest of 1% over the prime rate in effect, accruing monthly, on all unpaid patient balances.
I authorize AIMPC, SS and affiliated Providers to release any information required in the course of the patient?s examination of treatment to Insurance companies for payment. I hereby authorize any photocopies of this form to be valid as the original.<br/>I authorize AIMPC, SS and affiliated Providers to release information about all vaccinations given to me or to the person for whom I am authorized to consent, to the Arizona State immunization Information System (ASIIS), other health care providers and schools in order to avoid receiving unnecessary vaccinations and to the provide information about what immunizations have been received. I understand that I am not required to agree to the release of this information in order to receive the vaccine I request.
I authorize AIMPC, SS and affiliated Providers to take photographs of me. I understand that these photographs will be used for medical and administrative purposes, such as documenting or planning of care; or to identify patients. These photos will be stored in our electronic medical records.
I acknowledge that I received and read the Notice of Health Information Practices. I understand that my healthcare provider participates in Health Current, Arizona?s health information exchange (HIE). I understand that my health information may be securely shared through the HIE, unless I complete and return an Opt-Out Form to my healthcare provider.
I acknowledge that I have received a copy of AIMPC, SS ?Notice of Privacy Practices.? This notice describes how AIMPC, SS and/or ER may use and disclose my protected health information, certain restrictions on the use and disclosure of healthcare information and rights I may have regarding my protected information.
