HMMG Outpatient Consent

  1. CONSENT TO CARE: I wish to be treated by Hackensack Meridian Medical Group (HMMG). While I am a patient, I give permission to my doctor(s), employees of HMMG, and all other caregivers to provide care in ways they judge are beneficial to me. I understand that this care may include tests, examinations, and medical treatments. I understand that no guarantees have been or can be made to me about the outcome of the care that I receive.
  2. RELEASE OF INFORMATION: Hackensack Meridian Medical Group may see, release or confirm, all or part of any financial and medical information, including information regarding psychological, psychiatric, HIV and related diagnosis, drug and/or alcohol related illness, with any person, corporation or government agency that is or may be responsible to Hackensack Meridian Medical Group, the patient, and family member or employer for all or part of Hackensack Meridian Medical Group’s charges or verification of the same. I acknowledge that Hackensack Meridian Medical Group may be required to release patient information, including the highlighted above to federal and state agencies that monitor healthcare facilities, as well as any industries that produce and/or manufacture medical products. I authorize Hackensack Meridian Medical Group to provide access to my medical information to any person or organization in order to facilitate the provision of post visit care, treatment or services. I acknowledge that Hackensack Meridian Medical Group may access patient information from my medical record for purposes of research. I acknowledge that I have been informed that I may be contacted to participate in a research study and that I have the right to agree or decline to participate.
  3. PRE-CERTIFICATION REQUIREMENTS: I understand that my health insurance policy or benefits program (i.e., Medicare) may include certain conditions concerning pre-certification and provision of care by in-network providers and if I do not comply with those conditions, I may be responsible for charges that otherwise, might be covered by my insurance. I agree to pay such charges.
  4. Assignment of Benefits: I authorize my health insurance benefits to be paid directly to Hackensack Meridian Medical Group. Under the terms of my policy this payment may not exceed the balance due for services performed during this period of treatment. I further authorize Hackensack Meridian Medical Group to appeal on my behalf any denial by my insurance carrier.
  5. Medicare Payment Request: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administrator or its intermediaries or carriers any information needed for this or related Medicare claim. I request that direct payment of services on my behalf. I assign benefits payable for physicians’ services to Hackensack Meridian Medical Group.
  6. Outpatient Service “Medicaid”: I certify that services covered by this claim have been received and I request that payment for these services be made on my behalf. I assign the benefits payable for physician services to Hackensack Meridian Medical Group or authorize Hackensack Meridian Medical Group to submit a claim to Medicaid for payment on my behalf. I authorize the release of my medical information necessary to process this claim in accordance with program policy.

I have read the information contained above, any questions that had have been answered and I understand its contents. I attest that my personal information provided to Hackensack Meridian Medical Group is correct. I understand that providing incorrect information for the purpose of avoiding payment or for any other reason may be considered a violation of state and/or federal law. I understand that this form may be valid for the period of one year from the date signed for all physician services. I also understand that I have the right to ask questions at any time regarding my treatment, care or any terms contained in this consent. If I wish to revise my consent, I may do so by completing a new form or I wish to withdraw my consent, I must do so in writing.