Authorizations and Service Terms
Authorizations
Authorization for Treatment: I consent to the rendering of medical care which may include routine diagnostic procedures and such medical treatment as my attending physician(s) or other Mayo Clinic* (Mayo) medical staff consider to
be necessary. I may be offered medical services via telemedicine systems that involve the delivery of healthcare by electronic communication with a provider who is at a different physical location. I consent to initiating and/or receiving technology-based communications with my providers, including consulting services from a specialist performed virtually. I agree to be responsible for any charges that insurance does not pay. I understand that my medical care and treatment may be provided by physicians, including fellows and residents, medical and allied health students, physician assistants, nurses and other healthcare providers. I have read and understand this Authorization for Treatment and understand that no guarantee or assurance has been made as to the results that may be obtained.
Consent to Process and Share Medical Information**: I consent that as a
Mayo patient, my Medical Information will be used, processed, and disclosed
in accordance with U.S. law and as outlined in Mayo Clinic’s Notice of Privacy Practices (mayoclinic.org/npp). Furthermore, I authorize Mayo to use, process,
or disclose my Medical Information:
- To provide me with treatment and to coordinate my care;
- To bill for and collect payment for services, which may include communications
to my Payer(s)*** and Billing Addressee/Guarantor; - For healthcare operations as described in the Mayo Clinic Notice of Privacy Practices;
- For quality improvement and to coordinate my care. This may include sharing my past, current and future health, treatment and patient account records with my insurer(s) and other care providers;
- To accrediting and quality organizations, regulatory agencies, and public health reporting agencies;
Authorization to Assign Benefits and Release Information: I authorize my Payer(s) to pay directly to Mayo any benefits due under the terms of my healthcare plan(s), for services provided by Mayo. I understand Mayo reserves the right to refuse or accept assignment of medical benefits. If my healthcare plan(s) will not allow direct payment to Mayo or if Mayo chooses not to accept assignment of medical benefits, I agree to pay Mayo all healthcare payments I receive for services.
I authorize Mayo to contact my Payer(s) to obtain all pertinent financial information concerning coverage and payments made under my healthcare plan(s) and for my Payer(s) to release such information to Mayo. I hereby give Mayo authorization to appeal on my behalf for services provided at Mayo. I understand that this may waive my insurance appeal rights as a member when appealing the insurance denial. By signing this form, I understand that future appeal and adjudication rights for services may be exhausted according to the provision of my plan.
Service Terms
Statement of Financial Responsibility: I acknowledge I am responsible for all charges for services provided, including any amount not paid by my healthcare plan(s), or an out of state workers’ compensation payer, other than billing terms and restrictions under a government program or as prescribed by law in the state where medical services are provided. I authorize Mayo to apply any credit balance on my account to any amounts that I may owe to one or more Mayo entities.
I agree that Mayo may obtain financial information, including consumer credit reports to determine eligibility for financial assistance and/or payment options. Information on financial assistance is available by calling 844-217-9591, or at mayoclinic.org or mayoclinichealthsystem.org.
Dispute Resolution: I agree that any dispute (including personal injury claims) related to healthcare services rendered by Mayo is subject to the exclusive jurisdiction of the appropriate court in the state where the provider of the disputed services is physically located when the services are rendered and the law of that state. Any state court action must be venued in the county where the provider of the disputed services is physically located when the services are rendered. These agreements also apply to my legal representatives and next of kin.
Calling/Texting/Emailing: I agree that if I provide phone numbers or email addresses to Mayo, you may use them to text, email, or call me about my healthcare which includes, but is not limited to, appointment or prescription reminders, discharge planning, billing, research opportunities, your products and services, treatment alternatives, my general health or to provide regulatory notice in lieu of first class mail. These communications may use automated phone dialing and/or synthetic voices or prerecorded messages. I understand that when contacted in this manner, I will be given the opportunity to opt out of similar future communications. To learn more about opting out, visit mayoclinic.org/npp.
Notice of Privacy Practices: I acknowledge I have been presented with the Mayo Notice of Privacy Practices, which can be viewed at: mayoclinic.org/npp. I can request a paper copy during my visit or by contacting the Privacy Office.
Notice of Nondiscrimination: I acknowledge I have been presented with the Mayo Notice of Nondiscrimination, which can be viewed at: mayoclinic.org/non. I can request a paper copy during my visit or by contacting the Compliance Office.
* For purposes of this form, Mayo refers to Mayo Clinic in Arizona, Florida, Rochester, Mayo Clinic Health System and all affiliated clinics, hospitals, and entities, including employees, business associates, and agents.
** Medical information includes, but is not limited to, photographs taken for identification purposes, information related to psychologic, psychiatric, sickle cell anemia, HIV/AIDS, communicable diseases, genetic testing, and alcohol and drug abuse diagnosis and treatment.
*** For purposes of this form, Payer(s) includes, but is not limited to, insurance carriers, health-plan administrators, or any other payers including the Centers for Medicare & Medicaid (CMS) and their agents or review agencies.