Two locations in Jackson
Bolivar • Brownsville • Dyersburg
Lexington • Huntingdon • Martin • Paris
Ripley • Selmer • Trenton • Union City
By providing my initials, this is to serve as my electronic signature for these forms. If the patient is a minor, the
initials provided should be those of the patient's Guarantor or the Parent to be attending at the time of treatment.
I authorize West Tennessee Bone & Joint Clinic physicians and personnel to render medical treatment and evaluation needed. I further authorize order of x-rays, injections, casting or other diagnostic tests and treatment that may be necessary.
I understand that I have rights regarding my protected health information. These rights are governed by the Health Insurance Portability and Accountability Act of 1996. (HIPAA) I have been informed, and given the opportunity to review and secure a copy of the Clinic's Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information.
I hereby authorize the release and disclosure of my protected health information for treatment or payment for health care operations. I understand that any and all records concerning my personal and medical history are the confidential property of West Tennessee Bone & Joint Clinic, P.C.
I agree that West Tennessee Bone & Joint Clinic may request and use my prescription medication history from other healthcare providers or third-party pharmacy benefit payors for treatment purposes.
I agree that by providing my email address I am giving consent for West Tennessee Bone & Joint Clinic to set me up for a patient portal account. I also agree that by providing my cell phone number I am giving consent for West Tennessee Bone & Joint Clinic to contact me by this phone number.
You may restrict the individuals or organizations to which your health care information is released and you may revoke your authorization to us at any time, however, your revocation must be in writing and delivered to our address.
My insurance policy is a contract between myself and my insurance carrier. I am ultimately responsible for payment-in-full for all medical services provided to me. I acknowledge full financial responsibility for services rendered by West Tennessee Bone & Joint Clinic, P.C. I understand that payment of charges incurred is due at the time of service unless other definite financial arrangements are made prior to treatment. I agree to pay all collection and attorney fees, if applicable, in the event of default of payment of charges. I assign benefits to and authorize direct payment to West Tennessee Bone & Joint Clinic of which it is entitled. This also includes proceeds and benefits accruing under any settlement, structure or otherwise, or awarded in judgment for personal injuries caused by a third party for payment of services rendered by West Tennessee Bone & Joint Clinic. I agree to pay for all charges not paid pursuant to this agreement. I agree, in order for West Tennessee Bone & Joint Clinic and/or any of its Business Associates to service my account or to collect any amount I may owe,
West Tennessee Bone & Joint Clinic and/or any of its Business Associates may contact me at any telephone number associated with my account, including cellular numbers, which could result in charges to me. I may also be contacted by text message or e-mail, using only e-mail address I provide. Methods of contact may include using prerecorded/artificial voice messages and/or use of an automatic dialing service.