SUMMARY OF NOTICE OF PRIVACY PRACTICES

Uses and Disclosures of Health Information

We will use and disclose your health information in order to treat you or to assist other health care providers in treating

you (e.g. Surescripts, medication history download). We will also use and disclose your health information in order to

obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to you

by us or other health care providers. Finally, we may disclose your health information for certain limited operational

activities such as quality assessment, licensing, accreditation and training of students.

I may ask for a copy of SaVida Health, PC Notice of Privacy Practices at any time.

RESUMEN SOBRE LA NOTIFICACIÓN DE PRÁCTICAS DE PRIVACIDAD

Usos y Divulgaciones de Información Médica

Vamos a utilizar y divulger su información médica de salud para tratar a usted o para ayudar a otros provedores de salud

en su tratamiento (Surescripts, descargar historial de medicación). Tambien utilizaremos y divulgaremos su información de

salud con propocito de obtener el pago para nuestros servicios o para permitir compañias de seguro para procesar los

reclamos de seguro para los servicios prestados a usted por nosotros y otros provedores de salud. Finalmente, podemos

revelar su información médica para ciertas actividades operaciónales como evaluación de la calidad, licencias,

acreditatción y formación de los estudiantes.

Puedo pedir una copia del Aviso de Practicas en cualquier momento.

Patient Signature *

Clear

Patient Name *

Email *

Phone *

Date *

Staff Signature *

Clear

Staff Name *

Date *

ASSIGNMENT OF BENEFITS

I assign and authorize payment for any and all services rendered directly to SaVida Health and/or Agency from my

insurance company or third-party payor including, but not limited to, Medicare, Medicaid, commercial health insurance,

automobile no-fault insurance, and workers disability compensation insurance. If insured through Medicaid/Medicare, I

request payment of authorized benefits be made directly to SaVida Health and/or Agency for any services rendered to me,

including provider charges. In consideration of the professional services provided or to be provided to me, I agree to pay

all charges not covered by my insurance company or any applicable health benefit including, but not limited to,

deductibles, co-payments, non-covered services. I understand that it is my personal responsibility to pay SaVida Health

and/or Agency all charges for services rendered despite any disputes or disagreements between me and my insurance

company.

Patient Signature *

Clear

Patient Name *

Date *

Staff Signature *

Clear

Staff Name *

Date *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (XXX) XXX-XXXX for assistance. You can reply STOP to unsubscribe at any time.