ELM CITY CENTER

1314 West Walnut,

Jacksonville, Illinois 62650

Off: 217-245-9504

Fax: 217-245-2350  

Email: ecc@elmcity.org

Web page: www.elmcity.org

Work and Independence for people with disabilities.

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ELMCITY CENTER

 CONSUMER AGREEMENTS AND AUTHORIZATIONS

 CONSENT FOR TREATMENT. I hereby consent to the treatment provided by Elm City Center and its employees or designees. I authorize the mental and physical health care services deemed necessary or advisable by my caregivers to address my needs.

AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION.

I authorize use and disclosure of my personal health information for the purposes of diagnosing or providing treatment to me, obtaining payment for my care, or for the purposes of conducing the healthcare operations of Elm City Center. I authorize Elm City Center to release any information required in the process of applications for financial coverage for the services rendered. This authorization provides that Elm City Center may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agent.

ASSIGNMENT OF INSURANCE BENEFITS/ PAYMENT GUARANTEE/ COLLECTION FEE. I authorize payment to be made directly to Elm City Center for insurance benefits payable to me. I understand that I am financially responsible to Elm City Center for any covered or non-covered services, as defined by my insurer. I understand that if my account balance becomes overdue and the overdue account is referred to a collection agency, I will be responsible for the costs of collection including reasonable attorneys fees.

PRIVACY POLICY. I acknowledge having received Elm City Center’s, “Notice of Privacy Practices”. My rights including the right to see and copy my record, to limit disclosure of my health information, and to request an amendment to my record, is explained in the Policy. I understand that I may revoke in writing my consent for release of my health care information, except to the extent the Practice has already made disclosures with my prior consent.

 __________________________                   ____________________           ___________

Consumer or Authorized Person Signature     Relationship                                  Date

__________________________                   ____________________        

Witness Signature                                             Date

Consumer unable to sign. Verbal consent given. Reason_____________________________

 

Main Privacy Policy Page Notice of Privacy Practices ECC Employee Confidentiality Agreement
Rights of Consumers Protected Health Information Consumer Agreements and Authorizations

Elm City Center

An equal opportunity employer.

Revised - 10/3/2017