SPRINGFIELD HEART SURGEONS, LLC
PRIVACY PRACTICES AKNOWLEDGEMENT
Thank you for choosing Springfield Heart Surgeons, LLC to provide your care. We are required to provide you with a copy of our
Notice of Privacy Practices. To ensure that our records are accurate, please sign this form and return it to the receptionist to
acknowledge that you have been provided with a copy of our Notice of Privacy Practices. Please be aware, you may request a copy of
our Notice of Privacy Practices at any time.
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PRINT Name
Date
Signature of Patient (or parent if under 18 or legal guardian)
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Staff Initials
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FINANCIAL & BILLING POLICY AKNOWLEDGEMENT
Our financial and billing policy explains our billing procedures and outlines your financial responsibility. We ask that each patient
read this policy and sign below to acknowledge you have received a copy. If the patient is a minor (under 18) or is incapacitated, we
ask that the patient’s parent or legal guardian sign on the patient’s behalf.
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Signature of Patient (or parent if under 18 or legal guardian)
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Date
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CONSENT TO MEDICAL TREATMENT
I give my consent for the physicians and staff of Springfield Heart Surgeons, LLC to administer diagnostic and therapeutic treatment
of my illness and/or injuries and to perform minor operative procedures, as deemed necessary by the physician and staff. I consent to
a physical examination as necessary to diagnosis and treat my illnesses and /or injury. I understand that I am responsible for payment
of services rendered to me for the purpose of diagnosis and treatment.
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Signature of Patient (or parent if under 18 or legal guardian)
Date
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MEDICARE POLICY HOLDERS ONLY: (Please read and sign authorization below)
I authorize Springfield Heart Surgeons, LLC and any other holder of medical and other information about me to release to the Social
Security Administration and Centers for Medicare and Medicaid and its intermediaries and associates, any information needed for this
or a related Medicare claim. I permit a copy of this authorization to be used in place of the original and request payment of medical
insurance benefits be made to Springfield Heart Surgeons, LLC and its business partners. I assign payment of Medicare benefits
directly to Springfield Heart Surgeons, LLC for any service provided to me by its physicians and staff. I authorize any holder of
medical information about me to release any information needed to determine these benefits payable for related services.
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Signature of Patient (or parent if under 18 or legal guardian)
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Date
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ALL OTHER Insurance Policy Holders (NON MEDICARE): (Please read and sign the authorization below)
I authorize my insurance company to pay benefits on my behalf directly to Springfield Heart Surgeons, LLC. I authorize the release
of any information needed to process my claim to my insurance company and to the business partners of Springfield Heart Surgeons,
LLC as needed to process my claim. I authorize Springfield Heart Surgeons, LLC to release pertinent medical information to my
insurance company, when requested.
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Signature of Patient (or parent if under 18 or legal guardian)
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Date