660 COOPER RD. SUITE 300 WESTERVILLE, OH 43081

(614)389-3536

James W. McNeilis MD                                                                                                 

Consent for Care / Release of Records

I hereby authorize James W. McNeilis, MD, LLC and any employee working under the direction of the doctor, to provide medical care to me.  This care may include diagnostic, preventive, and therapeutic care. This includes common office procedures such as joint injections and soft tissue injections.  Dr. McNeilis has my permission to release any information needed for completion of claims for payment from third party payers, including but not limited to, insurance companies, health maintenance organizations, government agencies and their representatives.  I permit release of information concerning dates of treatment, condition, diagnosis, and treatment to my primary care physician, referring physician, and / or the referring facility for follow-up care.  I am aware this may include information regarding HIV or Aids, alcohol or drug abuse, and / or psychiatric treatment.  I have read, understand, and agree to this Consent for Care / Release of Records policy.

Patient or Responsible Party Signature______________________________________Date_______________

Assignment of Benefits

I acknowledge financial responsibility for all facility and physician fees including co-pays.  I understand that the physician billing office will file my insurance claim if my physician is a participating provider with my insurance carrier.  I assign direct payment to my physician all payments made under the provisions of my policy.  I further understand that any disputes of coverage are between my insurance company and me.  I will be responsible for payment for denied services, regardless of the outcome of the dispute.  I understand that this practice may refuse to provide service to me if I refuse to sign this consent.

Patient or Responsible Party Signature______________________________________  Date_______________

Medicare Patients Only

I request payment of authorized Medicare benefits be paid on my behalf to James W. McNeilis, MD, LLC for any services furnished to me through his office.  I authorize release of any medical information about me to determine payments to the Health Care Financing Administration or their agents.  This authorization is permanently in effect unless I choose to revoke it.

Patient or Responsible Party Signature_______________________________________Date________________