I, [Patient’s name], understand that this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I acknowledge that I have been provided with and understand that this facility’s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information.

I understand that:
• I have the right to review this facility’s Notice of Privacy Practices prior to signing this acknowledgement.
• This facility reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I've provided if requested.

By agreeing to communicate via email, you are assuming a certain degree of risk of breach of privacy beyond that inherent in other modes of traditional communication (such as telephone, written, or face to face). We cannot ensure the confidentiality of our electronic communications against purposeful or accidental network interception. Due to this inherent vulnerability, we will save email correspondence with you and these communications should be considered part of the medical record; therefore, you should consider that our electronic communications may not be confidential and will be included in your medical chart. Never send emails of an urgent or emergent nature and please contact the office if you have not received a reply within 48 hours.

Medication refill requests require a 7-day notice. If medication refills are required between appointments, please have your pharmacy send us a refill request. If you need to call for a refill you can do so during posted business hours. Refills will be communicated to your pharmacy within 48 hours during regular business hours. After hours and weekend requests may not be called in until the next business day. Please call with your prescription information and dosage as well as your pharmacy name, location and phone number. We will need this information to complete your refill request.

Nashville Neurocare Therapy / Neurocare Centers of America is contracted with Aetna, Anthem BCBS, Beacon, BCBS of TN, Humana, Medicare, Tricare, Optum United Healthcare, Ambetter Health (ACA products only), BHS, and Cigna Evernorth. We will file your insurance for you and you will be responsible for any deductible or copay as determined by your insurance company. For all other insurance companies that Nashville Neurocare Therapy is out-of-network with we are happy to file your insurance claims for you, however, arrangements for payment in full will need to be made at the time of service, except if your insurance is through Cigna.

If I choose to have my insurance filed for me, I hereby authorize payment by my insurance company directly to Nashville Neurocare Therapy.
I hereby authorize Nashville Neurocare Therapy to release any information my insurance company may require concerning patient care in regard to billing or prescription needs.

We do not overbook appointments therefore all slots are reserved specifically for the patient. If you need to change or reschedule an appointment, please call our office as soon as you can so we can accommodate other patients who wish to be seen. We require a 24-hour cancellation notice. Patients will be charged $50.00 if they cancel an appointment within the 24-hour time frame or if they fail to keep their appointment on the day it is scheduled.

Payment is required in full at the time of service. We accept credit/debit/checks/cash (please note we do not keep change in the office for cash payments but are happy to put a credit on your account. if you do not have exact cash). For your convenience we can keep a credit card on file to charge your deductible, copay or out-of-network payment at your appointments.

Credit/Debit Card Payment for missed or canceled appointments.

Patients are not obligated to continue treatment. If you decide to terminate at any time, you are encouraged to discuss your decision to terminate care with your doctor.

To reach your doctor after office hours call the main office at 615-465-4875 and leave a voicemail, your doctor will be contacted and return your call within 24 hours. If you are experiencing an emergency and cannot wait, please call 911.

I,[Patient's name] , agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.

Patients/Clients frequently request that we communicate with them by phone, voicemail, email or text. Nashville Neurocare Therapy respects your right to confidential communications about your protected health information (PHI) as well as your right to direct how those communications occur. Since email and texting can be inherently insecure as a method of communication, we will only communicate with you by email or text with your written consent at the email address or phone number you provide to us below. We will only be using email, text and voicemail to leave you messages confirming your appointment, schedule an appointment, regarding insurance or billing and medical record request. Please be aware that if you have an email account through your employer, your employer may have access to your email. When you consent to communicating with us by email or text you are consenting to email and texting communications that may not be encrypted. As well voicemail or answering machine messages may be intercepted by others. Therefore, you are agreeing to accept the risk that your protected health information may be intercepted by persons not authorized to receive such information when you consent to communicating with us through phone, voicemail, email or text. Nashville Neurocare Therapy will not be responsible for any privacy or security breaches that may occur through voicemail, email or text communications that you have consented to.

Information to be released: Intake/Psych eval, Medical records, Diagnoses, Medications w/ doses and durations.

Purpose of disclosure: Coordination of Care

This form, when properly completed, permits the release of confidential information about a person receiving services. Any information to be released under this form shall be released in accordance with HIPAA. The records released through this authorization are protected by HIPAA. Further disclosure of this information to parties other than those designated on this form is prohibited without the written consent of the person to whom the information pertains.

1. I understand that information used or disclosed pursuant to this authorization carries with it the potential for an unauthorized re-disclosure which may not be protected by Federal Privacy regulations.

2. I understand that signing this Authorization is voluntary and refusing to will not jeopardize my right to obtain present or future treatment except where disclosure of the information is necessary for the treatment.

3. I understand that I may revoke this Authorization by doing so in writing at any time; except to the extent that action has already been taken in reliance upon it, and that the revocation does not affect any information that was released before the revocation. Even if I do not revoke this Authorization, the Authorization expires automatically one (1) year from the date of signature.

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