Authorization To Pay Benefits To Physician: I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to my provider when they accept assignment.

Authorization To Release Medical Information: I hereby authorize my Provider to release any information necessary for my course of treatment.

I certify that the above information is correct as of the date signed.

I, the undersigned, hereby consent to the following Treatment: Administration and performance of all treatments Administration of any needed anesthetics Performance of such procedures as may be deemed necessary or advisable in the treatment of this patient Use of prescribed medication Performance of diagnostic procedures/tests and cultures Performance of other medically necessary or advisable based on the judgment of the attending physician or their assigned designees I fully understand that this is given in advance of any specific diagnosis or treatment. I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing. I understand that Vista Healthcare may include consent at satellite offices under common ownership. I, the undersigned, acknowledge that Vista Healthcare will use and disclose my information for the purposes of treatment, payment, and healthcare operations as described in the Notice Privacy Practices. A photocopy of this consent shall be considered as valid as the original. I acknowledge that I am able to have access to a complete copy of the Vista Healthcare “Notice of Privacy Practices”. I understand that if I have questions or complaints that I should contact the Privacy Official. Medicare Patients: I authorize to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable services to Vista Healthcare. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

I hereby authorize the release or use of my individually identifiable health information (protected health information or PHI) and medical information by ­­Vista Healthcare in order to carry out treatment, payment, or health care options. You should review the Practice's Notice of Privacy Practices for a more complete description of the potential release and use of such information, and you have the right to review such Notice prior to signing the Consent form. We reserve the right to change the terms of its Notice of Privacy Practices at any time. If we do make changes to the terms of its Notice of Privacy Practices, you may obtain a copy of the revised notice by writing our practice or requesting a copy from our front desk staff. You retain the right to request that we further restrict how your protected health information is released or used to carry out treatment, payment, or health care operations. Our practice is not required to agree to such requested restrictions; however, if we do agree to your requested restriction(s), such restrictions are then binding on the Practice.

Thank you for choosing Vista Healthcare.  Our team of providers is committed to providing you with quality and affordable health care.  We ask all patients to review and sign this policy, asking questions as necessary.  A copy will be provided to each patient upon request. If you do not agree to ALL of the terms listed below, we cannot proceed with your scheduled appointment.

1. Insurance: We accept assignment and participate in most insurance plans.  If your insurance is not a plan we participate in, payment in full is expected at each visit.  Knowing your insurance benefits is your responsibility.  Please contact your insurer with any questions you may have regarding your coverage to receive the maximum benefit. 2. Patient payment: All copayments and deductibles are to be paid at the time of service.  This arrangement is part of your contract with your insurance company.  3. Registration: All patients must complete our patient information form, which will be entered into our medical records system to maintain accurate information for proper billing.  We must obtain a copy of your driver’s license and current valid insurance card to provide proof of insurance.  If you fail to provide us with correct insurance information, or your insurance changes and you fail to notify us in a timely manner, you may be responsible for the balance of the claim.  Many insurance companies have a time limit as to when claims can be filed; For example, if a claim is not received within 30 days of the date of service, it can be deemed ineligible for payment and you will be responsible for the balance if you fail to provide us with complete and accurate information.   4. Claims: We will submit your claims and assist you in any way we reasonably can to help get your claims paid.  Your insurance company may not accept information from our office and may need information from you.  It is your responsibility to comply with their request.  Please be aware that the balance of your claim is your responsibility whether your insurance company pays or not.  Your insurance benefit is a contract between you and your insurance company.  5. Uninsured patients: We offer a cash pay discount to our patients who do not have insurance.  Please be advised that the discount is only good when the charges are paid at the time of service.  If the charges are not paid at the time of service, the discount will be removed and payment of the full charge will be expected before the next visit.  If a balance remains, you will receive a monthly statement that is due upon receipt.  Any account balance over 90 days will be subject to review for collection action. 6. Credit and collection: If your account is more than 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full.  Partial payments will not be accepted unless otherwise negotiated.  Please be aware that if a balance remains unpaid, it may be sent to a collection agency.  In the event any amount is referred to a third party debt collection agency, you agree that in addition to any other amount allowed for by law, (such as interest, court costs, reasonable attorney’s fees, etc), you will also be responsible for a collection fee of up to 40% of the principal amount owing as allowed by Utah code Annotated, sec.12-1-11.  7. Missed appointments: Our policy is to charge up to $75.00 for each missed appointment (no shows) canceled within 24 hours of appointment time. These charges will be your responsibility and billed directly to you.  Please help us serve you better by keeping your regularly scheduled appointment. 8. Credit Card: Patient agrees to have credit card on file. This card will be charged for missed appointments. If card is not kept on file, a statement will be sent and payment must be made within 30 days of receipt to avoid account being sent to collections.