Privacy
We value your privacy and are committed to making you look good and feel great, while being discreet and treating your case confidentially and respectfully
Prior to your appointment please review our privacy statement. You can download a copy by clicking here. Please complete the form and bring it with you for your appointment
Consent to the Use and Disclosure of Health Information for Treatment, payment, or Healthcare Operations
Your consent: I understand that as part of my health care, this organization originates and maintains health records describing my health history, diagnoses, and treatment. I understand that is required by federal government. I understand that this information serves as:
1.A basis for planning my care and treatment
2.A means of communication among the health professionals who contribute to my care.
3.A source of information for applying my diagnosis/es and other health information to my bill (s).
4.A means by which my health plan or health insurance company can verify the services billed were provided and a tool for routine health care operations in this organization and making sure that the professionals who provide this care are competent to do so.
5.I have been provided with a Notice of Information Practices that provides specific examples and descriptions of how my personal health information is used and disclosed.
6.I have the right to review the Notice of Information Practices prior to signing this consent
7.SECOND TO NATURE can change its Notice of Information Practices but must notify me of those changes before they are put into practice and will mail me a copy of the new Notice to the address that I have provided.
8.I may revoke this consent in writing at any time. Further, I am aware that SECOND TO NATURE can proceed with used and disclosures that pertain to treatment, payment, or healthcare issues that took place before the consent was revoked.
9.I have been provided a copy of Medicare Supplier Standards and Medicare Beneficiary Complaint form
10.I authorize that payment of authorized Medicare or other insurance benefits be made either to me or on my behalf for any services furnished to me to be paid to provider accepting assignment
11.I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operation and the SECOND TO NATURE is required to agree to these restrictions. I request the following restrictions as to the use or disclosure of my health information and I understand the following warranties on my products: _______________________________________________________________________________________
I understand that Second To Nature has the right to:
Notify me in order to update records, set appointments and verify appointments for my care
Disclosure information to any medical staff necessary to process my treatment and/or claim
Disclosure information to insurance companies, etc. necessary to process my treatment and/or claim
SECOND TO NATURE POLICY
1. Will file insurance unless otherwise specified. All Medicare filed
2. Assignment accepted from Medicare unless upgrade is requested
3. Approved amount accepted from insurance companies unless specified
4. Patient is held responsible for payment in the event insurance does not pay, deductible is not met, upgrade requested by patient. Patient will be informed previous to the fitting if products are upgrade. Please provide your signature below to indicate that you have read the above consent.
This also serves as my signature on file.
Signed and effective this date:_____________________________
_____________________________________________________ ________________________________________________
Signature of Patient or Legal Representative Witness
_____________________________________________________
Print Name
Our Mission is to make you feel good about yourself both inside and out. When you feel confident and elegant you look better
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900 W. Faris Road, Greenville, SC 29605
621 E. Main Street, Easley, SC 29640