Coastal Concierge - Disclosure Contract

1HIPAA AUTHORIZATION
2MEDICARE & COMMERCIAL
3NO SHOW / CANCELLATION FEE

  • HIPAA AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

  • This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

  • Patient Information

  • MM slash DD slash YYYY

  • Disclosing Party

  • The disclosing party can use or disclose the following health information.

    - All of my health information
    - My health information relating to the following treatment or condition: [listed below]
    - My health information covering the period from [listed below]
    - Other [listed below]
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • The above party may disclose this health information to the following recipient:

    David Weitzman MD PC
    802 41' Ave S, N Myrtle Beach, SC 29582-5155
    P: 843-491-3007 F:888-895-4537
  • MM slash DD slash YYYY


  • I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party. I understand that uses and disclosures already made based upon my original permission cannot be taken back.

    I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization. I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

  • Reset signature Signature locked. Reset to sign again
  • Reset signature Signature locked. Reset to sign again
  • MM slash DD slash YYYY

  • MEDICARE & COMMERCIAL PRIVATE CONTRACT

  • This contract is entered into by and between David Weitzman MD PC (hereinafter called "physician"), whose principal medical office is located at 802 41St Ave S, North Myrtle Beach, South Carolina [name of beneficiary] and (hereinafter called "beneficiary"), who resides at [address of beneficiary], and shall become effective on [date of contract signed] and shall not expire (the "opt out period"), unless otherwise terminated in accordance with the 42 U.S.C. 1395a; 42 C.F.R. 405, Subpart D.

    Physician Obligations

    The physician acknowledges that he is not excluded from Medicare under sections 1128, 1156, 1892 or any other section of the Social Security Act. This contract shall not be entered into with the beneficiary, or the beneficiary's legal representative, during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. This contract (with original signatures of both parties to this contract) will be filed in the EMR system for the duration of the opt-out period, and that it shall be made available to the Centers for Medicare and Medicaid Services (CMS) upon request. A copy of this contract was supplied to the beneficiary, or to his or her legal representative, before items or services have been furnished to the beneficiary under the terms of this contract.

    Beneficiary Obligations

    The beneficiary, or his or her legal representative, accepts full responsibility for payment of the physician's charge for all services furnished by the physician. No payment will be provided by Medicare for items or services furnished by the physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. Understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician. Agrees not to submit a claim, nor ask the physician to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare.

    The beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. This agreement shall not be entered into with the physician during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440. Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
    The beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the beneficiary, or to his or her legal representative, before items or services have been furnished to the beneficiary under the terms of this contract. This written private contract contains sufficiently large print to ensure that the beneficiary is able to read this contract.

    I understand that during the opt-out period, a Medicare Advantage plan may not by law make any payments to the physician for any Medicare items and services furnished to the beneficiary under this contract.

    David Weitzman, MD
  • MM slash DD slash YYYY
  • Reset signature Signature locked. Reset to sign again
  • Reset signature Signature locked. Reset to sign again
  • MM slash DD slash YYYY

  • NO SHOW / CANCELLATION FEE


  • We understand that you may sometimes need to reschedule appointments. When we make your appointment please understand we are reserving time for you to see a provider. This courtesy makes it possible to give the best service here at Dr. Weitzman's office. If you need to reschedule an appointment, please call the office at least 24 hours in advance.

    If you have not showed for your appointment you will be charged a $50 no show fee. If you cancel without rescheduling within 2 weeks you will be charged a $50 cancellation fee. We thank you for your trust in us here at Dr. Weitzman's office.
  • Reset signature Signature locked. Reset to sign again
  • MM slash DD slash YYYY