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Acknowledgements Form: All Patients Must Complete

Chestnut Family Practice, PLLC Release Forms & Disclosures

(Street, City, State, Zip)
It is your responsibility to understand what your insurance company will or will not cover, if you are in or out of network, your deductibles, your copay's, and if you need prior authorization for any procedures prior to them being performed. (Write self insured if you do not have health insurance)
If applicable
If applicable
If applicable
If applicable (PCP #)
(Name, Location), none
(Name, location) None

HIPPA Release Authorization

Chestnut Family Practice, PLLC adheres to the very strictest confidentiality policies. We will not release any medical information to anyone that you do not consent to release information. This includes your spouse, relatives, other family members, and friends. Dependents must complete this form to authorize the release of protected health information to the account holder. I authorize the following individuals to my personal health record:

Primary Account Holder Information:

My protected health information is individually identifiable health information, including demographic information collected from me or created or received by a health care provider, a health plan, my employer, or a health care clearinghouse, and relates to: (i) my past, present, or future physical or mental health condition; (ii) the provision of the health care to me; or (iii) the past, present or future payment for the provision of health care to me.

In accordance with the provisions of the Health Insurance Portability and Accountability Act (HIPAA), I, the undersigned, grant permission to disclose protected health information (as defined in HIPAA) to the following person or persons:

Please include first or last names of the parties you wish to include, if you do not authorize anyone please say NONE.
Click all that apply
Click all that apply

I may revoke this Release at any time by notifying Chestnut Family Practice, PLLC in writing or through your message center in the patient portal. I understand that by granting this Release, the person who obtains this information may disclose it to other individuals with or without my consent and in so doing, the information would no longer be protected under HIPAA. Further you acknowledge and understand that the Chestnut Family Practice, PLLC Privacy Policy has been provided to you in paper copy upon request, is available on our website and forms database.

Financial & Credit Card Disclosure

Thank you for trusting Chestnut Family Practice, PLLC as your healthcare provider.

We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read this agreement fully and by clicking the acknowledge button you confirm you understanding your patient financial responsibilities and our policies.

In consideration of the receiving services from Chestnut Family Practice, PLLC, you agree:

1. All services are provided to you with the understanding that you are responsible for the cost regardless of your insurance coverage. If you would like to know the cost of a service, please inquire prior to treatment. You are responsible for knowing what services are or are not covered. Please, KNOW YOUR BENEFITS.

2. Patients are responsible for the payment of copays, coinsurance, deductibles and all other procedures or treatments not covered by their insurance plan. Payment is due at time of service, and for your convenience, we accept cash, checks, and most major credit cards.

3. At Chestnut Family Practice, we require keeping your credit card on file as a convenient method of payment for the portion of services that your insurance doesn't cover, but for which you are liable. Your credit card information is kept confidential and secure and payments to your portion of your deductible if applicable will be processed when services are rendered. If you do not have a deductible your card is processed only after the claim has been filed and processed by your insurer, and the insurance portion of the claim has paid and posted to the account.

4. By my authorization below, I hereby allow Chestnut Family Practice and the physicians, staff and hospitals associated with Chestnut Family Practice to release medical and other information acquired in the course of my treatment to the necessary insurance companies, third party payers and/or other physicians or healthcare entities required to participate in my care.

5. By my clicking below, I hereby authorize assignment of financial benefits directly to Chestnut Family Practice and any associated healthcare entities for my services rendered as allowable under standard third party contracts. I understand that I am responsible for charges not covered by this assignment.

6. By my clicking below, I authorize Chestnut Family Practice to securely store my credit card information and only charge it should I have an outstanding balance or any leftover balance from a processed claim in the future. I am aware that the storage system used is fully compliant to the highest level of credit and storage security regulations. Once stored, I am aware that only the last five digits of my card are viewable by personnel.

I have read, understand, and agree to the provisions of this patient financial responsibility and automatic credit card payment authorization form.

Note: We do not offer payment plans or monthly billing statements. Payment is due in full based on your estimated deductible and reimbursement.

Anti-Discrimination Policy:

Discrimination is Against the Law.

Chestnut Family Practice, PLLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Further it does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Chestnut Family Practice, PLLC provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English.

Qualified interpreters

Information written in other languages

If you need these services, contact our office manager. If you believe that Chestnut Family Practice, PLLC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Vaccination Policy

We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.

We firmly believe in the safety of our vaccines.

We firmly believe that all children and young adults should receive all the recommended vaccines per the schedule published by the Centers for Disease Control and Prevention and the American Academy of Pediatrics.

We firmly believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities.

We firmly believe that thimerosal, a preservative that has been in vaccines for decades and remains in some vaccines, does not cause autism or other developmental disabilities.

We firmly believe that vaccinating children and young adults may be the single most important health-promoting intervention we perform as healthcare providers, and that you can perform as parents/caregivers.

The recommended vaccines and the vaccine schedule are the results of years and years of scientific study and data gathering on millions of children by thousands of our brightest scientists and physicians. This said, we recognize that there has always been and will likely always be controversy surrounding vaccination. Indeed, Benjamin Franklin, persuaded by his brother, was opposed to smallpox vaccine until scientific data convinced him otherwise. Tragically, he had delayed inoculating his favorite son Franky. The boy contracted smallpox and died at the age of 4, leaving Franklin with a lifetime of guilt and remorse. In his autobiography, Franklin wrote:

"In 1736, I lost one of my sons, a fine boy of four years old, by the smallpox...I long regretted bitterly, and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen."

The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even discussing whether they should be given. Because of vaccines, many of you have never seen a child with polio, tetanus, whooping cough, bacterial meningitis, or even chickenpox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent or even lazy about vaccinating. But such an attitude, if it becomes widespread, can only lead to tragic results.

After publication of an unfounded accusation (later retracted) that MMR vaccine caused autism in 1998, many Europeans chose not to vaccinate their children. Because of under immunization, Europe experienced large outbreaks of measles, with several deaths from disease complications. In 2012, there were more than 48,000 cases of pertussis (whooping cough) in the United States, resulting in 22 deaths. Most victims were infants younger than six months of age. Many children who contracted the illness had parents who made a conscious decision not to vaccinate. In 2015, there was a measles outbreak in Disneyland, California (probably started by an infected park visitor who had traveled from the Philippines). The outbreak eventually spread to 147 people and, again, many were too young to have been vaccinated.

When you don't vaccinate, you take a significant risk with your child's health and the health of others around them. By not vaccinating, you also take advantage of thousands of others who do vaccinate their children, thereby decreasing the likelihood that your child will contract a vaccine - preventable disease.

We are making you aware of these facts not to scare you or coerce you, but to emphasize the importance of vaccinating your child. We recognize that the choice may be a very emotional one for some parents. We will do everything we can to convince you that vaccinating per the schedule is the right thing to do. However, should you have doubts, please discuss these with your healthcare provider in advance of your visit. In some cases, we may alter the schedule to accommodate parental concerns or reservations.

Please be advised, however, that delaying or "breaking up the vaccines" to give one or two at a time over two or more visits goes against expert recommendations, and can put your child at risk for serious illness (or even death) and goes against our medical advice as providers at Chestnut Family Practice, PLLC. Such additional visits will require additional co-pays on your part.

Please realize that you will also be required to sign a "Refusal to Vaccinate" acknowledgement in the event of lengthy delays. Because we are committed to protecting the health of your children through vaccination, we require all our patients to be vaccinated.

Infants will receive all age-appropriate recommended vaccines by three months of age, with additional recommended vaccines as well as booster doses by two years of age. Children will receive additional recommended booster doses by the time they are seven years old, and will be given recommended 11 - 12-year preteen vaccinations by the time they are 13 years old. We will complete 16 year teen vaccinations before each child's 17th birthday. And, we will also give your child/teen an annual influenza vaccination unless they receive it at a school clinic or pharmacy.

Finally, if you should absolutely refuse to vaccinate your child despite all our efforts, we will ask you to find another healthcare provider who shares your views. We do not keep a list of such providers; nor would we recommend any such physician. Please recognize that by not vaccinating, you are putting your child at unnecessary risk for life threatening illness and disability, and even death.

As medical professionals, we feel very strongly that vaccinating your child on schedule with currently available vaccines is absolutely the right thing to do to protect all children and young adults.

Thank you for taking the time to read this policy. Please feel free to discuss any questions or concerns you may have about vaccines with any one of us.

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