As a DOM Patient, I voluntarily consent to the rendering of such care and treatment as the DOM providers and personnel, in their professional judgment, deem necessary for my health and well-being. My Consent shall include all diagnostic procedures and/or medical, lab, surgical or x-ray treatment which in the judgment of my attending physician or his authorized agent, may be considered necessary or advisable. I also authorize release of information to the Poison Center if required as part of my treatment.
I Understand and agree that DOM may contact me using automated calls, email, and text messaging sent to my landline and mobile device. These communications may notify me of preventive care test, tests results, treatment recommendations, outstanding balances, or any communication from DOM.
I understand that I may voluntarily "opt-in" to receive automated text messaging communications from DOM and its partners by informing my provider's staff or visiting "My Profile" on my Patient Portal, and agreeing to any additional Terms and Conditions established by my mobile carrier.
I hereby acknowledge that I have received DOM's Financial Policy, the sharing of my information via HIE and consent to my treatment by DOM provider.
PAYMENT IS DUE AT THE TIME OF CONSULT OR OFFICE VISIT.
WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, OR MONEY ORDERS.
WE OFFER EXTENDED PAYMENT (BUDGET) PLAN. Contact our billing office to make arrangements at 724-261-4080.
I request that payment of authorized Medicare benefits be made on my behalf to the provider to any services furnished to me by the physician or provider. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits payable for related services
DiCesare Orthopedic Medicine has a NOTICE OF PRIVACY PRACTICES which describes how we may use disclose your protected health information. You may review our current notice prior to signing this acknowledgment. It is located on our website "www.greensburgortho.com".
I acknowledge that I have received the NOTICE OF PRIVACY PRACTICES for DiCesare Orthopedic Medicine.
Please specify to whom other than yourself, we may release your Protected Health Information(PHI).
Please list all the medication that you are taking (including over the counter medications) and the medical reason you take each medication:
Please list your surgical history:
Please mark all that apply to your IMMEDIATE FAMILY: (Parents, Siblings, and Grandparents only)
Review of Systems: (Please circle all that apply to what you are currently experiencing with your overall health)
Please sign your name in the area below