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Designation Statement

To designate another person(s) to speak on your behalf, please fill out the upper portion of this form. Or you may decline this option by signing the lower portion.

I, , designate the following person(s) to be able to speak with Dr. Mist, or other staff members, should it be necessary, on my behalf. I hereby give permission to the office of Dr. Heidi C. Mist MD Inc. through its physicians and staff to release to my designee any information about my medical condition or medical needs or the status of my account and I release Dr. Mist MD Inc. and its physicians and staff, from any claim of confidentiality in connections with the release of this information.

Name of Designated Person 1:

Relationship: Phone Number:

Name of Designated Person 2:

Relationship: Phone Number:

Name of Designated Person 3:

Relationship: Phone Number:

I decline to designate another person to speak with my physician or clinical staff.

Patient's Name: Date:

Office Policies

Refills may be requested through the office or through your pharmacy. We require 72 hour notice for refill requests. Refills may be denied by the provider, but the pharmacy or patient will be notified as to the reason why. Medications will not be filled outside of regular office hours.

Office hours are Monday through Friday, 8:00 am to 12:30 pm and 1:30 pm to 4:00 pm.

We require 24 hour notice for cancelling or rescheduling an appointment. Same day cancellation or "no shows" will be charged $80. If a patient has three same day cancellations or "no shows" they may be discharged from the practice.

A notice of Privacy Practices is available for your review. If you are not familiar with the terms of the Health Information and Patient Portability Act, please ask for a copy. Signing this agreement acknowledges that you have been given the opportunity to review this information.

Financial Policies

All charges for services rendered are the patient's responsibility. We bill your insurance as a courtesy to you. Co-payments, unpaid deductibles and fees for non-covered services are due at the time of service. Insurance coverage will be verified at the time of service. If the Insurance carrier fails to verify coverage, the patient must pay for services in full at the time of the visit. Returned checks will incur a $25 charge and additional payment by check will not be accepted until both the services rendered charges and returned check fee have been paid in full. Unpaid balances over 45 days past due may be referred to collections.

There is a $25 fee for completing forms (Disability, DMV). There is a fee of $25 for any prior authorization requests to be done by the office. This includes imaging and medication requests.

Requests for medical records must be made in writing and the practice may take up to 20 working days to complete the request. There is no charge for electronically-faxed records. Copied and mailed records will be charged $0.50 per page over 20 pages.

Consent to Treatment

I am voluntarily seeking healthcare and hereby consent to medical treatment, procedures, laboratory tests, and healthcare services. I have the right to refuse specific treatment or procedures. I agree that I have read and understand this document in its entirety. I have had the opportunity to ask and have my questions answered to my satisfaction. I certify that I am the patient or am duly authorized by the patient or by law to execute the agreement. I permit reproduction of this authorization to be used in place of the original assignment. I authorize the release of my medical records necessary to process my insurance claims. I hereby assign to Heidi C. Mist M.D. the medical benefits I am entitled from my insurance company.

Patient's Name: Date:

Authorization to Disclose Health Information

Patient Name:

Date of Birth:

I hereby authorize (previous provider):

and/or their agents or representatives to review, make copies of and release my medical information to:

Heidi C. Mist M.D

PO Box 741

Red Bluff, CA 96080

Fax: 888-217-8306

The information to be released or disclosed is as follows:

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must present my revocation in writing, I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. If I fail to specify an expiration date, event or condition in writing, this authorization will expire in six months.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that if the recipient of my information in Section 1, above is not a healthcare provider, a health plan, or health care clearing house, or not an entity required to comply with federal or state health privacy regulations, my heath information may be further disclosed by such recipient, and my information may no longer be protected by state and federal laws. If this authorization is for the disclosure of substance abuse information, the recipient may be prohibited from disclosing the substance abuse information under federal substance abuse confidentiality requirements.

I understand that may be required to pay a fee for this copying service as governed by the California Health and Safety Code #123110 and that my insurance company will not pay for this service.

Initial:

I acknowledge receipt of a signed copy of this authorization. Initial:

Patient or Personal Representative's Name: Date: Relationship to Patient:

Authorization to Release Restricted Information

I understand and hereby consent to the release of any and all alcohol and/or drug abuse information; information: relating to sexually transmitted diseases; Acquired immune Deficiency Syndrome (AIDS); Human Immunodeficiency Virus (HIV); or psychiatric treatment records under the same conditions outlined above. I understand that such information cannot be released without my specific consent.

Patient of Personal Representative's Name: Date:

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Timestamp

Audit

December 12, 2021 4:24 pm PDT

New Patient Documents Uploaded by Heidi Mist - drheidimist@gmail.com IP 141.193.89.16

December 12, 2021 5:39 pm PDT

Docu Sign - drheidimist@gmail.com added by Heidi Mist - drheidimist@gmail.com as a CC'd Recipient Ip: 206.214.236.70