Mountain West Plastic Surgery
60 Four Mile Drive, Suite 11
Kalispell, MT 59901
Phone: (406) 609-0210
Fax: (406) 609-0211
Monday–Friday: 8 a.m.–5 p.m.
HIPAA Privacy Notice
KALISPELL REGIONAL HEALTHCARE
PATIENT CONSENT AND FINANCIAL AGREEMENT
Patient Name: _____________________________________________________________ Patient DOB: ___/___/___
Welcome to Kalispell Regional Healthcare (“KRH”). Thank you for choosing us for your care and treatment. KRH is an integrated health system that includes a number of organizations and Healthcare Services providers. A list of the KRH organizations and services offered is being provided to you along with this Patient Consent and Financial Agreement (“Agreement”).
Please review this Agreement carefully. Except in cases of emergency care, we must have a signed and dated Patient Consent and Financial Agreement before Healthcare Services (defined below) can be provided to you. If you have any questions about this Agreement, our KRH registration staff will be happy to answer your questions before you sign.
If, at a later date, you have additional questions about your medical bills or need to make corrections to the information you have provided to KRH, please contact the KRH Patient Accounting office by calling (406) 756-4408, Monday through Friday, except holidays, from 8:00 a.m. through 5:00 p.m.
CONSENT FOR TREATMENT AND CARE
You hereby consent to any Healthcare Services (as defined below in this paragraph) provided by KRH and by Healthcare Services providers who are independent from KRH but who are authorized to provide Healthcare Services to you as a KRH patient. These independent, non-KRH-employed providers include, but are not limited to physician and other medical and allied health professional staff members of Glacier Regional Pathology, Ltd.; Clinical Pathology Associates, LLC; Northern Rockies Anesthesia Consultants, PLLC; Northwest Imaging, PC; and Silvertip Emergency Physicians, PC (collectively, “KRH Affiliated Providers”). You understand and agree that resident physicians and other Healthcare Services education students may participate in or be observers of the Healthcare Services you receive at KRH. These residents and students will be supervised by qualified instructors and KRH staff. Your Healthcare Services may include, but are not limited to, hospital inpatient, outpatient, and/or emergency services; physician office services; diagnostic procedures; transportation; nursing care; and other Healthcare Services and products. You acknowledge that no guarantees have been made regarding the outcome of these Healthcare Services. If you are not able to sign this Agreement personally, then the consent for your care and treatment: (1) may be given by your representative(s) who are legally authorized to make decisions and sign this Agreement on your behalf, or (2) shall be implied in cases of emergency.
REPORTING OF IMMUNIZATION RECORDS
The Montana Department of Public Health and Human Services (DPHHS) has requested that we seek your consent to share your/your child’s immunization data with the DPHHS Immunization Information System (IIS). DPHHS may release IIS data to other public health agencies as well as to your/your child’s healthcare providers to assist in your/your child’s medical care and treatment. In addition, DPHHS may release IIS data to schools in order to comply with immunization requirements. You can always choose to opt out at a later time and/or have your/your child’s immunization record removed at any time by contacting your county’s health department. You understand that any such revocation will not be effective as to uses and/or disclosures already made prior to opting out.
THIS IS NOT A CONSENT TO RECEIVE ANY IMMUNIZATION, IT IS ONLY A CONSENT TO REPORT YOUR/YOUR CHILD’S IMMUNIZATION DATA TO THE DPHHS IIS.
If you are OPTING OUT of reporting you/your child’s immunization data to DPPHS, check the box, sign and date in the area below.
Name of Patient / Date
Signature of Patient/Parent, Authorized Representative or Guardian, if applicable
Agreement to Pay Charges and Billing Statements – In consideration of the Healthcare Services provided to you, you and/or any individuals who are directly responsible for your medical bills, such as a parent or guardian, (collectively, “Guarantors”) agree to pay KRH’s billed charges related to those Healthcare Services (“Charges”), minus any contractual reductions from the Charges agreed to by KRH with your Health Plan Payor (if applicable) and any other reductions to which you may be entitled, such as under the KRH financial assistance policy. You understand and agree that: (1) any KRH Affiliated Providers that provide Healthcare Services to you in connection with your care and treatment at KRH may have separate billing and collection practices that result in one or more separate bills for which Guarantors are responsible to pay; (2) the terms of this Agreement prevail over any conflicting terms and conditions in any other contract or plan to which you claim to be a party or a beneficiary; (3) it is possible that your Health Plan will determine that Healthcare Services provided to you are not Covered Services and that you will be responsible for paying for those Healthcare Services; and (4) the terms of this Agreement are governed by the laws of the State of Montana.
Financial Assistance – KRH has a Financial Assistance policy available to patients who qualify. If you are interested in learning more, please ask our staff for a copy of the policy. The Financial Assistance Policy is available on the Kalispell Regional Healthcare website under the heading “Pay Bill.”
PATIENTS WITH OUT-OF-NETWORK INSURANCE/OTHER HEALTH PLAN PAYOR – You understand and agree that except when prohibited by applicable law, KRH may collects its charges from guarantors when KRH does not have a written contractual agreement with an insurance company or other health plan Payor outlining an agreed upon rate of payment for the healthcare services provided (called “out-of-network”.) You understand and agree that when receiving healthcare services from KRH on an out-of-network basis, Guarantors may also be required to make payment at the time of service.
Payment – Guarantors may make payment to KRH: (1) at the time Healthcare Services are provided to you; (2) in accordance with billing statements received from KRH; or (3) in accordance with a payment schedule that is agreed upon by both KRH and Guarantor(s). If Guarantors fail to make any scheduled payment when due, you understand and agree that: (1) KRH may declare the entire balance to be immediately due and payable, and (2) Guarantors will be responsible for all costs associated with collection of the owed charges, including reasonable attorney’s fees. You acknowledge and agree that payments to KRH Affiliated Providers must be made to them in accordance with their payment rules. No partial payment of the amount owed by Guarantors to KRH (whether the payment says it is in full payment or not) will be treated as full payment without a specific separate written agreement between Guarantors and KRH that is signed by both parties. KRH may also assign past due accounts to third party collection agencies.
Third Party Liability – In the event that any third party is or could be liable for part or all of the charges for the Healthcare Services provided to you (such as due to an automobile accident), you acknowledge that Guarantors remain responsible for the portion of the Charges that you are responsible to pay, but KRH is also legally authorized to bill for and recover from that third party the full charges for the Healthcare Services. KRH may do this whether or not KRH has also submitted a bill for the services to any federal, state, or private healthcare insurance/health benefits plans (collectively a “Health Plan Payor”) covering you. Guarantors will not be responsible for any amounts in excess of the portion of the charges that you are responsible to pay, but KRH may recover from the third party an amount that permits KRH to receive up to the full charges for the Healthcare Services provided. Guarantors also acknowledge that KRH may submit a Healthcare Provider/ Facility Lien, as allowed by Montana Code Annotated Title 71, Chapter 3, Part 11, to the third party.
Refunds ‒ Please let us know if your address changes so that we can contact you in the event that your account is overpaid and you are entitled to a refund. If we cannot locate you over a period of five (5) years after your right to a refund has been identified, Montana law requires us to send your refund to the Montana Department of Revenue. Montana law permits us to impose a charge against your refund during the time it remains unclaimed. KRH’s annual charge is Ten U.S. Dollars ($10.00) and will be imposed at the beginning of each annual period.
Without waiver or limitation of the above Financial Agreement, you hereby: (1) authorize KRH, on your behalf, to submit a claim for and to accept, negotiate and deposit payment from any Health Plan Payor and other responsible third party providing coverage for, or who may be otherwise liable for, payment of any of the charges for the Healthcare Services provided to you (“Responsible Third Parties”); and (2) direct those Health Plan Payors and Responsible Third Parties to which KRH submits a claim for payment to make payment(s) directly to KRH. You understand and agree that KRH: (1) is not required to submit a claim for payment to anyone other than Guarantors; but (2) may choose to submit a claim to one or more of your Health Plan Payors and Responsible Third Parties. This authorization is limited only to the rights, on your behalf, to submit a claim for and to accept, negotiate and deposit payment from any Health Plan Payor and Responsible Third Parties. It does not entitle KRH to any other rights or bind KRH to any responsibilities that you may have under any Health Plan Payor agreements, third party liability agreements or policies or any other theories of coverage or liability. You hereby consent also to KRH providing notice of this authorization to your Health Plan Payors and other Responsible Third Parties.
APPOINTMENT OF KALISPELL REGIONAL HEALTHCARE (KRH) AS AUTHORIZED REPRESENTATIVE
I understand that KRH may assist in pursuing a claim or appeal of a denied claim. I authorize and appoint KRH to act on my behalf and/or on behalf of my covered child/ dependent (under 18 years of age) as my authorized representative with any insurance carrier with whom valid insurance coverage exists for medical services. I further direct that any payment made by any insurance carrier as a result of a successful appeal is to be paid directly to KRH. This authorization and appointment will remain valid until such time as I revoke this authorization and appointment in writing to KRH.
RELEASE OF INFORMATION
You acknowledge that KRH and KRH Affiliated Providers are authorized by law to release medical and account information necessary for the purposes of treatment, payment, and healthcare operations. This information may be released to Health Plan Payors, liability insurance companies, billing companies, collection agencies, attending/consulting healthcare providers, governmental programs or medical review organizations and otherwise as permitted or required by law.
CONSENT TO CONTACT
You agree that, in order for KRH and/or KRH Affiliated Providers to request your feedback about the Healthcare Services provided to you, to service your account, or to collect any amounts you may owe, KRH, KRH Affiliated Providers and their business associates, including without limitation any independent contractors, account management companies or collection agencies, may contact you by telephone, SMS text message or email at any cellular or residential telephone number or email address provided during your registration process. These methods of contact may include auto-dialed, prerecorded and/or artificial voice message calls or texts as permitted by law.
You acknowledge that KRH maintains a safe for securing money and/or other valuables. KRH shall not be liable for the loss of or damage to your money, valuables, articles of unusual value, or any other personal property (“Property”), if not deposited with KRH for storage in KRH’s safe.
BY SIGNING BELOW, YOU CONFIRM THAT YOU: (1) UNDERSTAND AND AGREE TO THE TERMS OF THIS AGREEMENT, (2) HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT THIS AGREEMENT AND (3) HAVE RECEIVED AND REVIEWED AND, IF NEEDED, COMPLETED THE FOLLOWING:
• FEDERAL TRUTH IN LENDING ACT NOTIFICATION
• LIST OF KRH ORGANIZATIONS AND SERVICES
• PATIENT BILL OF RIGHTS & RESPONSIBILITIES
• KRH JOINT NOTICE OF PRIVACY PRACTICES
• AN “IMPORTANT MESSAGE FROM MEDICARE FOR MEDICARE BENEFICIARIES” or “IMPORTANT MESSAGE FROM TRICARE FOR TRICARE
• ADVANCE DIRECTIVE – You have been advised of your right to formulate and execute an Advance Directive and have been provided with
written information regarding the same.
Patient Signature/Authorized Representative/Guarantor Date
Guardian or Legal Representative if not patient (please print) Relationship to Patient
Patient Name ________________________________________ Acct # ________________________________________________________
Witness _____________________________________________ MRN # _______________________________________________________