I hereby authorize Greater Chicago Specialty Physicians (“GCSP”) to release any and all medical information to the above-named insurance carriers or their representatives (and or attorney) for the purpose of claims administration and evaluation, utilization review, and financial audit. I further authorize any person or entity responsible for the payment of my medical bill or any representative on their behalf to pay GCSP directly for charges of services rendered to me. I further understand that I am fully responsible for any financial balance resulting from insurance non-covered services, co-payments, deductibles, co-insurances and any fees/charges associated by sending my account to collections. I agree to have my records sent to any requesting legal agencies or insurance companies with the understanding that a non-designated party may inadvertently see such information.

I acknowledge that I have received a copy of Greater Chicago Specialty Physicians’ (“GCSP”) Notice of Privacy Practices, which describes how medical information about me may be used and disclosed and how I can get access to this information.

I acknowledge that I have read the Office and Financial Policies which is available on our website and in our office for review. I clearly understand and agree to be bound by its terms and understand that agreement with this policy is necessary for treatment at this facility. I also understand that these policies may be updated at any time without notice but can be obtained in person at our office or on our website.

As the parent/guardian of the child/minor, I hereby give permission to the physicians and staff GCSP to treat the child/minor in the event that a medical emergency arises, and I am unable to personally consent to the treatment. I also agree to be responsible to GCSP for charges for medical services rendered.

I have read and understand the policies above and I agree to be bound by its terms.

I ,do hereby state that I am authorized to sign this permission on behalf of the patient on the following basis: Relationship to Patient

Patient Portal: Sign up for GCSP Patient Portal?

By signing up for the Patient Portal, you acknowledge that you are aware that you will receive appointment reminders, lab results, and other practice related information through this and email and authorize Greater Chicago SSecialW PhVicianV (³GCSP´) to contact you via this method regarding any communication.

Please WLFN preferred methods of communication below

In place of or in addition to communication via the Patient Portal, please FKHFN any additional preferred method(s) for us to contact you and leave a message. If we are unable to reach you through your preferred method, we will contact you via any method necessary, except direct email, regarding medical and financial information. Please note, an appointment reminder call is a courtesy to our patients. Although we do our best to make these calls, this is not a guaranteed service.

I give authorization to the employees of GCSP to discuss my medical and/or financial information with the person(s) listed below. These person(s) will also serve as my emergency contact(s) unless I specify otherwise.

By signing below, I authorize GCSP to contact me and release my information by the above methods. I also understand that it is my responsibility to provide contact information where I may be reached at all times as certain tests may require urgent attention.

To serve our patients is our greatest privilege and we want to continue to be able to provide the very best care to you. In order to remain in business and continue to provide excellent and personalized care to our patients, we need to make sure that patient financial responsibilities are being met in a timely manner by having a guarantee of payment in place.

• How does the automatic credit card on file process work and when will I be charged: You will receive a letter in the mail from your Insurance carrier that explains how much of your office visit they pay and how much you owe. This is called an Explanation of Benefits (EOB). This letter tells you exactly, according to your health insurance coverage, how much is determined to be “patient responsibility”. We receive the same EOB and we will charge the credit card on file the exact amount as per the EOB that is stated to be patient responsibility. Once charged, we will mail/email you a receipt of payment. For Infusion and/or Injection services with eligible copay assist in place, your credit card will be charged accordingly. For Medicare patients with supplement insurance, your credit card or cheque on file will only be charged after your supplemental insurance processes our claim and there is still a remaining balance.
• What is a deductible? An annual deductible is the dollar amount you must pay out of your own pocket during your plan year for medical expenses before your insurance begins to pay. Your insurance company must receive a claim to process in order to apply balances towards your deductible.
• Do I need to sign a CCOF Authorization form? Yes. The CCOF Authorization form confirms your enrollment with this program and authorizes our billing department to process patient balances accordingly.
• When do I give you my credit card and is it stored securely? We require you to sign the CCOF Authorization form and provide us with your credit card in person. We will swipe your credit card with an encrypted reader that will securely upload your credit card number into our third party vendor’s website. Our vendor is a certified Payment Card Industry (PCI)-Data Security Standard (DSS) company that provide a robust payment card data security process, which includes prevention, detection and appropriate reaction to security incidents.
• Can I keep my HSA card on file? Yes, you can keep your HSA card on file, however, we may require an additional card to be kept on file should the funds in your HSA account become insufficient.
• What if I need to dispute my bill? We will always work with you to resolve any issues and will refund you if we have made a billing error. We will only charge the amount that we are instructed by your insurance carrier to collect from you in the same way that we normally determine how much to send you a statement for in the mail. If you disagree with how your insurance carrier processed the claim you will need to contact their customer service department directly.
• What if I refuse to give you my credit card? If you do not wish to keep a card on file, we will expect a cash deposit from you at the time of service. Our retainer amount is $300 and will need to be replenished when your balance reaches $100.00.
• What if my credit card is denied? If your credit card is denied for any reason, services at GCSP will not be rendered until an updated credit card is on file with our billing office.

I authorize Greater Chicago Specialty Physicians to capture my credit card/cheque information and securely store my credit card/cheque on file.

I, the undersigned, authorize and request Greater Chicago Specialty Physicians (GCSP) to charge my credit card, indicated above, for past and current balances due for services rendered that my insurance company identifies as my financial responsibility. This will also apply to any bank fees (including chargeback fees) that apply and GCSP’s cancellation/no show policy fee. (NO REFUNDS WILL BE ISSUED)

This authorization relates to all payments not covered by my insurance company for services provided to me by GCSP.

Any patient disputes relating to CCOF MUST be dealt directly with GCSP’s billing department.

If the credit card is denied for any reason, I understand that services will not be rendered until an updated credit card is on file.

This authorization will remain in effect until I cancel this authorization. To cancel, I must give a 60-day notification to GCSP in writing and the account must be in good standing.

IF YOU DECLINE CCOF, THEN YOU MUST KEEP

• This authorization will remain in effect for one year from the date of authorization written below. You or your Personal Representative may revoke this authorization at any time by providing written notice as specified in our Notice of Privacy Practices.
• There will be a charge for processing this request in accordance with Illinois law.
• Once this information is shared with the recipient you specified above, how that recipient further discloses it may no longer be protected under federal and state privacy regulations.
• The matters discussed on this form release Greater Chicago Specialty Physicians, its employees, officers, directors, and business associates from any legal responsibility or liability for the disclosure of the above information.