QRS Patient Portal

FINANCIAL POLICY/ MISSED APPOINTMENT CHARGE

Payment is required at time service is rendered. Returned checks are subject to a service charge.
A minimum of 48-hours advance notice is required if a patient must cancel or reschedule their appointment.
A missed appointment fee will be charged for missed appointments without the minimum 48-hour notice.

QRS Patient Portal

ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize direct payment of surgical/medical benefits for services rendered by the Physician(s) in person or under Physician(s) supervision. I understand that I am financially responsible for any balance not covered by my insurance company, or any service my insurance company deems not covered by my policy.

QRS Patient Portal

AUTHORIZATION TO RELEASE OR OBTAIN INFORMATION

I hereby authorize my providers to release or obtain any medical or incidental information (to include HIV testing and/or treatment records, substance abuse, and/or Psychiatric care or treatment) that may be necessary for either medical care or in processing application for financial benefit.
This includes all records obtained electronically (including hospitals).

QRS Patient Portal

ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE AND REQUEST TO RESTRICT/EXCEPTION TO RELEASE PROTECTED HEALTH INFORMATION

We are required by law to provide you with a copy of our Notice of Privacy Practices. Should you wish to allow or restrict access of your medical records to person(s), please inform an office personel.

QRS Patient Portal

CHI Terms and Conditions

Please click here to view the full Catholic Health Initiatives, Inc. Terms and Conditions.