I certify that the above information is correct. I understand that I am financially responsible for all services not paid by my insurance. I am also responsible for any deductibles, copayments, or non-covered services. I authorize e Omni Cosmetic, Wayzata Surgical Center, and/or Central MN Anesthesia Providers to release any medical or other information necessary to process my claims. I also request payment of payment of government or private benefits either to myself or to the party who accepts the assignment. This is a permanent authorization that I may revoke at any time by written notice.
Privacy Practice and Insurance Acknowledgment
Under the Health Insurance and Portability and Accountability Act of 1996 (HIPPA), you have certain rights regarding the use and disclosure of your protected health information. These rights are more fully described in Omni Cosmetic's Notice of Privacy Practices. Omni Cosmetic is permitted to revise its Notice of Privacy Practices at any time. The undersigned acknowledges that you were offered and or received the Minnesota Patient Bill of Rights & Privacy Policy information. I also understand that my insurance will be billed for all consultations related to billable medical conditions.
Electronic Communication Consent
By signing below, I acknowledge that I am aware that communication between N Omni Cosmetic and myself may sometimes be through electronic communication, i.e.: email, voice mail and/or text messaging. Communication of these types will be based on the comfortability of the individual patient/client. Each patient/client has the right to review or receive a copy of the communication policy upon request.