Request for Confidential Communication or your Protected Health Information

Request for Confidential Communication of your Protected Health Information

Please circle your response to the following:

May we leave message concerning your appointments with co-worker, receptionist or secretary that regularly answer your calls? (Yes, No, or N/A)

May we leave messages on a voiced mail at work? (Yes, No, or N/A)

May we discuss your appointment/treatment with your spouse? (Yes, No, or N/A)

If you are over the age of 18, may we discuss your appointments and/or treatment with your children? (Yes, No, or N/A)

You must inform us in writing if you wish to change the manner in which this office Communicates to you. Thank you

Credit Card/Debit Card Authorization

Heal 360 submits claims to insurance carriers as a convenience to all our patients. At this time we re- quest authorization to balance bill major credit card or debit card to cover amounts determined by your insurance to be your responsibility.

Upon receipt of an explanation of benefits from your insurance carrier any unpaid portion of your claim will be billed to your credit card or debit card. Should insurance pay in full, your account will not be charged.

All credit/debit card information will remain absolutely confidential and securely stored by First Data. Heal 360 will not store any banking account data.

I hereby authorize Heal 360 to charge any and all outstanding balances, after insurance company reimbursement or denial, to my credit/debit card. I understand that I will not receive a statement if there is no balance due after processing my credit card for payment.

Card holder's Signature*

Date

Please do not submit any Protected Health Information (PHI).

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