CONSENT TO UNENCRYPTED ELECTRONIC COMMUNICATIONS
Email is a widely used form of communication. However, email transmissions are not inherently secure. Information sent via email is not encrypted and can be available for anyone to see. Therefore, sending information (especially sensitive or private information) via email is not a secure or confidential means of communicating. There are a number of risks associated with transmitting confidential information via standard email services.
By accepting this form, I consent and agree to allow Erik Thor Bendiks MD PC d/b/a Georgia Spine and Orthopaedics (“GSO”) to communicate with me via unencrypted email and understand that unencrypted email is not secure and the security and confidentiality of this communication cannot be guaranteed. If I prefer not to authorize the use of email, GSO will continue to communicate using the patient portal, U.S. Mail or telephone.
IN A MEDICAL EMERGENCY, I SHOULD NOT USE EMAIL. I SHOULD CALL 911. Furthermore, email is not appropriate for urgent problems during business hours. I should call GSO office at 404-596-5670.
Emails sent to GSO should not be time sensitive. While GSO will try to respond to email messages daily, GSO cannot guarantee that any email will be read and responded to within any particular period of time.
GSO will not correspond via email with any email address except those email addresses provided by me. I have received and read the Notice of Privacy Practices for information as to permitted uses and disclosures of my health information and rights regarding privacy matters. I understand it is my responsibility to inform GSO of any changes to the email address(es) I provided.
I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and present my revocation to GSO. I understand that the revocation will not apply to information that has already been used or disclosed in response to this authorization. I understand that this authorization is valid unless and until written notice is provided to revoke this authorization. I understand that GSO cannot require me to sign this authorization as a condition of treatment
I understand that the definition of “email” as referred to in this consent refers to electronic mail, text messages, and any form of communications transmitted using electronic devices and systems.
I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM. I UNDERSTAND THE RISKS ASSOCIATED WITH UNENCRYPTED EMAIL/TEXT AS A FORM OF COMMUNICATION AND DO HEREBY GIVE PERMISSION TO GEORGIA SPINE AND ORTHOPAEDICS TO SEND PERSONAL HEALTH INFORMATION VIA UNENCRYPTED EMAIL TO THE EMAIL ADDRESS(ES) I PROVIDED.


AUTHORIZATION AND CONSENT TO TREATMENT
I consent to the provision of treatment that may include diagnostic procedures and medical treatment by ERIK THOR BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS (“GSO”). I understand special consent forms may need to be signed for specific procedures.
I consent to treatment by GSO with the understanding that I will furnish accurate information regarding my injuries and will cooperate when referred to other physicians or medical facilities for examination or testing. My non-compliance with the plan of treatment may result in the refusal of further care and discharge from GSO.
I acknowledge that no guarantees have been given to me as to the outcome of any examination or treatment.


PATIENT AUTHORIZED COMMUNICATION
I hereby authorize GSO to leave protected heath information pertaining to my care by voice mail/email/text and will assume responsibility to notify them whenever this information changes. I authorize GSO to leave said messages with the person(s) I have designated as my approved contacts or emergency contacts. I understand that Protected Health Information (PHI) used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer protected by Federal or State Law. I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and present my revocation to GSO. I understand that the revocation will not apply to information that has already been used or disclosed in response to this authorization. I understand that this authorization is valid unless and until written notice is provided to revoke this authorization. I understand that GSO cannot require me to sign this authorization as a condition of treatment unless the provision of health care by GSO is for the sole purpose of creating PHI for disclosure to a third party legally authorized to receive such information.
Spouse or Significant Other
Parents
Other Relationship


PHARMACY CONSENT
I understand that GSO will transmit my prescriptions electronically as permitted, to the pharmacy that I delegate as my primary pharmacy provider. Prescription data collected will be stored in GSO’s practice electronic medical records system and will become a part of my personal medical record. I hereby give permission to allow GSO to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. By signing this consent, I give GSO permission to collect and give my pharmacy and health insurer permission to disclose information about my prescriptions that have been filled at any pharmacy or covered by any health plan. This includes prescriptions to treat AIDS/HIV and medications used to treat mental health issues.
THE INFORMATION I HAVE PROVIDED IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND ABILITY. I HAVE READ/COMPLETED OR HAVE HAD THIS ACKNOWLEDGEMENT AND CONSENT FORM READ/ COMPLETED
FOR ME AND IT HAS BEEN EXPLAINED TO MY SATISFACTION AND APPLIES TO ALL ERIK THOR BENDIKS MD PC d/b/a GEORGIA SPINE & ORTHOPAEDICS PROVIDERS.


ASSIGNMENT OF BENEFITS AND PATIENT RESPONSIBILITY
I authorize the healthcare professionals at ERIK THOR BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS (“GSO”) to render healthcare services to me as deemed necessary and advisable by the designated healthcare professional. I agree to cooperate with all reasonable requests of GSO in rendering said services.
I authorize GSO to bill my insurance carrier and request such payments to be made directly to GSO.
I authorize GSO to act on my behalf and as my representative to request reconsideration (internal and/or external review process) by my managed care plan or utilization review entity for coverage or grievance review.
While I understand GSO will attempt to obtain eligibility information, authorizations, and referrals on my behalf, I also understand that it is in my best interest to verify with my insurance carrier what my benefits are and if GSO is participating on my plan. GSO does not guarantee benefits or coverage at the time of service.
I understand that any amounts not paid by my insurance are my responsibility and are due at the time of service.
I understand all co-payments and deductibles must be paid and are due at the time of service.
I also authorize GSO to release medical or other information required by my insurer, other payers and their agents, government agencies or their designees for review of the care provided to me.
I hereby assign and authorize payment directly to GSO of: (i) any private healthcare insurance, (ii) medical payment insurance, (iii) injury benefit due because of liability of a third-party, and (iv) proceeds of all claims resulting from the liability of a third party, payable by any party, organization, attorney, etc., to or for me, unless and until my account with GSO for the services or series of related services provided by the GSO Providers (collectively, the “Services”) is paid in full, upon discharge or completion of the Services. I hereby authorize GSO to apply and file for all such payments referenced herein on my behalf, and direct that such payments be made directly to GSO.
I agree that any claim which may result from the care provided to me by the doctors, physician assistants and other healthcare providers at any location for GSO facility shall be subject to the laws of Georgia.
I also agree that before any lawsuit is filed related to the care provided to me, I must attempt to resolve any claim through mediation. This agreement is binding on me and any person making a claim on my behalf.


MEDICAL TREATMENT AND PAYMENT FOR SERVICES FOR MINORS
Georgia law requires that a parent or guardian (with written permission of parent) authorize treatment for an unemancipated minor (under age 18). It is that adult’s responsibility to ensure payment at the time of service if the minor is not covered by a verifiable insurance plan.


PATIENT FINANCIAL RESPONSIBILITIES
I understand that by receiving services provided by GSO Providers (collectively, the “Services”) I am personally responsible for any portion of the GSO invoice(s) for Services that remains outstanding. I agree to execute any necessary documents to direct all third-party benefits and other payments for Services to GSO.
I understand, if my account becomes past due or delinquent, GSO will take necessary steps to collect this debt and my delinquent account may be transferred to a collection agency and reported to credit bureaus. I understand that GSO has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. If a lawsuit is filed to collect on my account, exclusive jurisdiction shall be in the state and federal courts of Fulton County, Georgia. I wave all objections to personal jurisdiction and venue in Fulton County, Georgia. I agree to pay GSO’s reasonable attorneys’ fees and costs incurred collecting on my account.
I have health insurance I want to file
I do NOT have health insurance


CONSENT TO MAIL MEDICATIONS TO MY HOME
GENERAL INFORMATION
I understand Georgia Spine & Orthopaedics (GSO”) is licensed to dispense certain medications (“Medications”). I understand GSO is willing to mail Medications to my home address via First-Class Mail. I understand there is a risk, however, that: (i) someone may steal Medications out of my mailbox, (ii) a family member or other person authorized to collect the mail from my mailbox may wrongfully take Medications, (iii) Medications may get lost or stolen in transit from their office to my mailbox, or (iv) Medications may be delivered to the wrong address. Additionally, a collateral risk of mailing Medications is that my Protected Health Information (PHI) is discovered by an unauthorized party. I understand GSO is not responsible if sending Medications results in an unauthorized person seeing my PHI or obtaining Medications. Knowing these risks and accepting the liability and responsibility for same, I agree and authorize GSO to mail my Medications to my home address.
ACCEPTANCE, CONSENT, AND WAIVER
I agree to allow GSO to mail my prescriptions directly to the address I provided. This mailing will include my PHI, such as my name and the medication that I am taking and may include other sensitive facts about my health. I understand that if another person accesses my prescription, that person will see my PHI. If I do not want to accept the risk that someone may take my prescription and/or access my PHI, I should not agree to allow GSO to mail my prescriptions to me.
I accept these risks and agree that GSO may mail my prescriptions to me via First-Class Mail. I agree to inform GSO immediately if my address changes. I will not hold GSO responsible if my PHI is seen by an unauthorized person or my medications are taken/obtained by an unauthorized party. I RELEASE, WAIVE, DISCHARGE AND PROMISE NOT TO SUE OR BRING ANY CLAIM OF ANY TYPE AGAINST GSO FOR LOSS, DAMAGE, INJURY, OR LIABILITY RELATING TO THE MAILING OF MY MEDICATIONS TO MY DESIGNATED ADDRESS.
PATIENT ACKNOWLEDGMENT
This form gives you the facts about and risks involved in receiving my Medications by mail. By accepting this form, I confirm that I have read, understand, and agree with these Terms of Use for receiving my Medications by mail.
My acceptance of this form indicates that I freely consent to receive my medications from GSO by mail to the address that I provided. I also confirm by accepting this form that:
I have been able to ask any questions. All my questions have been answered. No guarantees have been made.
I agree to the terms as noted above


DISCLOSURE OF OWNERSHIP
Erik Thor Bendiks, MD, PC d/b/a Georgia Spine & Orthopaedics and Surgery Center of Roswell are physician owned facilities and your physician may have a financial interest in the center. You have the right to choose where you receive medical and surgical services including an entity in which your physician may have a financial relationship. You will not be treated differently by your physician if you choose to use a different facility. If desired, your physician can provide information about alternative providers.
By accepting this Acknowledgment of Disclosure, I acknowledge that I have read and understand the foregoing notice regarding physician ownership and patient safety measures.


HIPAA ACKNOWLEDGEMENT
In accordance with the Health Insurance Portability and Accountability Act (HIPAA), by accepting this form, I acknowledge that I was given access to and offered a copy of the Notice of Privacy Practices for Erik Thor Bendiks, MD, PC d/b/a Georgia Spine & Orthopaedics.


AUTHORIZATION TO RELEASE MEDICAL RECORDS
I authorize the release of medical record(s) of the above person. This information is being release to Georgia Spine & Orthopaedics for purpose of continued medical care.
“I understand that I have the right to revoke this authorization at any time by presenting a written revocation to the Medical Records Director or designee. I understand that the revocation will not apply to any information that has already been released in response to this authorization.
This expiration will expire one (1) year from the date of my signature.”
“I have read and understand the contents of this authorization and I confirm that the health care provider may use/disclose my protected health information to the persons and/or organization named above.
Please release to:

Erik Thor Bendiks MD PC, DBA Georgia Spine and Orthopaedics Dr. Erik Bendiks, Dr. Vinson Smith, and Dr. Daryl Figa.
11650 Alpharetta Hwy, Suite 100 Roswell, GA 30076
Email: Clinical@GASpineOrtho.com Fax: 770-338-9103
Phone: 404-596-5670



PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases. Your “protected health information” means any written and oral health information about you, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.
I. Uses and Disclosures of Protected Health Information
The Organizations may use your protected health information for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless the facility has obtained your authorization, or the use or disclosure is otherwise permitted by the HIPAA privacy regulations or state law. Disclosures of your protected health information for the purposes described in this Privacy Notice may be made in writing, orally, or by facsimile.
A. Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.
B. Payment. Your protected health information will be used, as needed, to obtain payment for the services that we provide.
C. Operations. We may use or disclose your protected health information, as necessary, for our own health care operations to facilitate the
function of Georgia Spine & Orthopaedics and to provide quality care to all patients.
D. Other Uses and Disclosures. As part of treatment, payment and health care operations, we may also use or disclose your protected health information.
II. Uses and Disclosures beyond Treatment, Payment and Health Care Operations Permitted without Authorization or Opportunity to Object Federal privacy rules allow us to use or disclose your protected health information without your permission or authorization for several reasons including the following:
A. When Legally Required.
B. When There Are Risks to Public Health.
C. To Report Suspected Abuse, Neglect or Domestic Violence.
D. To Conduct Health Oversight Activities.
E. In Connection with Judicial and Administrative Proceedings.
F. For Law Enforcement Purposes.
G. For Research Purposes.
H. In the Event of a Serious Threat to Health or Safety.
I. For Specified Government Functions.
J. For Worker’s Compensation.
The facility may release your health information to comply with worker’s compensation laws or similar programs.
III. USES AND DISCLOSURES PERMITTED WITHOUT AUTHORIZATIONS BUT WITH OPPORTUNITY TO OBJECT
We may disclose your protected health information to your family member if it is directly relevant to the person’s involvement in your care or payment related to your care. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.
You may object to these disclosures. If you do not object to these disclosures, in the exercise of our professional judgment, that it is in your best interest for us to make disclosure of information that is directly relevant to that person’s involvement with your care, we may disclose your protected health information as described.
IV. USES AND DISCLOSURES WHICH YOU AUTHORIZE
Other than stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have acted in reliance upon the authorization. We specifically require your written authorization for marketing or the sale of your protected health information. If our facility maintains psychotherapy notes, we will require your written authorization for the use or disclosure of psychotherapy notes other than by the creator of those notes, by the facility for its training programs or for the facility to defend itself in a legal action brought by you.
V. YOUR RIGHTS
You have the following rights regarding your health information:
A. The right to inspect and copy your protected health information. You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your surgeon and the facility uses for making decisions about you. If information in a “designated record set” is maintained electronically, you may request an electronic copy in a form and format of your choice that is readily producible or, if the form/format is not readily producible, you will be given a readable electronic copy in a timely manner not to exceed 60 days. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.
We may deny your request to inspect or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.
To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed on the last page of this Privacy Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs
incurred by us in complying with your request. Please contact our Medical Records Custodian if you have questions about access to your medical record.
B. The right to request a restriction on uses and disclosures of your protected health information. You may ask us not to use or disclose certain parts of your protected health information for the purposes of treatment, payment and health care operation. You may request that we do not file a claim to your health plan if an agreed upon amount is paid out-of-pocket. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notification purposes as described in this Privacy Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply.
The facility is not required to agree to a restriction that you may request unless your request related to a disclosure to a health plan for items or services that were paid in full by you or someone other than the health plan and the disclosure is not required by law. We will notify you if we deny your request to a restriction. If the facility does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting the Privacy Officer using the contact information below.
C. The right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not require you to provide an explanation for your request. Requests must be made in writing to our Privacy Officer using the contact information below. D. The right to request amendments to your protected health information. You may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. Your request may be denied if we did not create the PHI, if the amendment is not part of normal record keeping of PHI, and if the amendment would never be included for inspection by any other group or party and if we believe the record is accurate and complete without the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Requests for amendment must be in writing and must be directed to our Privacy Officer whose contact information is listed on the last page of this Privacy Notice. In this written request, you must also provide a reason to support the requested amendment.
E. The right to receive an accounting. You have the right to request an accounting of certain disclosures of your protected health information made by the facility. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time sought for the accounting. Accounting requests may not be made for periods of time more than six years. We will provide the first accounting you request in any 12-month period without charge, Subsequent accounting requests may be subject to a reasonable cost-based fee.
F. The right to obtain a paper copy of this notice. Upon request, we will provide a separate paper copy of this notice even if you have already received a copy of the notice or have agreed to accept this notice electronically.
G. I understand that, by law, my medical record belongs to Erik Thor Bendiks MD PC d/b/a Georgia Spine & Orthopaedics. The
right to request a copy of your medical records in accordance with State and federal laws. Any requests for copies of paper medical
records will be processed within 30 days. You can request a copy by calling (404) 596-5670.
VI. OUR DUTIES
The facility is required by law to maintain the privacy or your health information and report to you any breach of unsecured protected health information. We are also required to provide you with this Privacy Notice of our duties and privacy practices. We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all future protected health information that we maintain. If the facility changes this Notice, we will post notification at each office location and provide a copy of the revised Notice on our website.
VII. COMPLAINTS
You have the right to express complaints to the facility and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the facility by contacting the Privacy Officer verbally or in writing, using the contact information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
VIII. CONTACT PERSON
The facility’s contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. If you feel that your privacy rights have been violated by this facility you may submit a complaint to:
Georgia Spine & Orthopaedics Attn: Privacy Officer
11650 Alpharetta Hwy, Suite 100,
Roswell, GA 30076
Phone: 404-596-5670
Anonymous HIPAA Hotline: 844-333-0850
If you are unable to get your issue resolved, you may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling 1-877-696-6775.


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THIS PHYSICIAN PRACTICE LIEN AGREEMENT (the “Agreement”) is hereby entered into by and among:
("Patient"), (“Attorney”) and Erik T Bendiks, MDPC
WHEREAS, Patient was injured in an accident or incident and is seeking medical/diagnostic care from Provider for his/her injuries; and
WHEREAS, Attorney represents Patient in a claim or lawsuit (the “Legal Action”) to recover damages arising
from the accident or incident, including medical/diagnostic expenses; and
WHEREAS, Provider has agreed to render treatment to Patient without requiring payment at the time of rendering services;
NOW THEREFORE, in consideration of the premises, the mutual covenants contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:
1. Patient acknowledges that, in accordance with the Health Information Portability and Accountability Act of 1996 ("HIPAA"), Patient's medical information relating to the Legal Action may be shared to manage and expedite Patient's medical treatment. Patient authorizes Provider to release any information needed by Attorney to pursue the Legal Action, including without limitation information (including billing information) regarding the examination, treatment, procedures and services rendered by Provider. Patient authorizes Attorney to secure, release, and disclose such medical treatment information with individuals and entities as deemed necessary to pursue the Legal Action, and Patient further agrees that examinations, diagnoses, medical treatments, films and reports can be shared with necessary parties involved in the Legal Action. Attorney acknowledges that Attorney has obtained a Release of Medical Information from Patient for purposes of communications regarding Patient's medical information. Patient expressly authorizes Attorney to keep Provider advised of the progress of the Legal Action at reasonable intervals.
2. Patient hereby grants to Provider a lien on the proceeds of any settlement, judgment or verdict in the Legal Action which may be paid to Patient or to Attorney. Patient hereby notifies Attorney that Patient is giving Provider a lien on these benefits or settlement proceeds, and Patient hereby authorizes and directs Attorney to withhold such funds from any settlement, verdict or judgment that is rendered in the Legal Action and pay Provider directly from any such proceeds any sums due for medical services rendered to Patient. This lien is irrevocable and can only be satisfied by full payment of all sums due for medical services rendered, unless Provider expressly agrees otherwise in writing. Patient understands that any settlement, verdict or judgment proceeds cannot be disbursed to Patient without first satisfying this lien.
3. Should a dispute arise regarding payment of Provider’s charges, Patient authorizes and directs Attorney to hold in escrow all monies sufficient to satisfy this lien until the dispute can be resolved. Patient and Attorney acknowledge that it would be a violation of Attorney’s ethical duties to disburse the disputed funds prior to resolution of the lien dispute.
4. Patient understands and agrees that even though this lien has been given, Patient remains personally responsible for payment in full of Provider’s fees for all services rendered, including without limitation fees for services provided at Provider’s office locations (e.g., exams and office visits, x-rays, injections, DME, PT, supplies, medications and fees for Provider’s services (e.g., surgical services) provided at any other facility. Patient is solely responsible for making appropriate arrangements for payment of such fees, including but not limited to insurance benefits. Patient acknowledges that this obligation to pay Provider’s fees is not dependent on the outcome of Patient’s court case. Provider and Patient agree that in the event it is necessary to enforce this Agreement in a court of law, then in addition to all damages and costs, the prevailing party shall be entitled to reasonable attorney's fees in the amount of 25% of the amount at issue.
5. Provider hereby agrees to await Patient’s payment of Provider’s fees until the Legal Action is resolved by settlement,
judgment or verdict, except to the extent that payment is available from Patient’s medical insurance.
6. Patient and Attorney hereby expressly acknowledge the validity and enforceability of Provider’s lien as of the date Provider’s treatment of Patient commences and expressly agree to be bound by the terms of this Agreement. Patient and Attorney expressly acknowledge that this Agreement constitutes actual notice of Provider’s lien pursuant to OCGA §44-14-471(b), and Patient waives the right to assert any defense to the validity and enforceability of Provider’s lien based on Provider’s failure to perfect the lien in accordance with OCGA §44-14-471(a). Patient hereby directs and authorizes Attorney to provide actual notice of Provider’s lien to all parties involved in the Legal Action in accordance with the requirements of OCGA §44-14-471(b), and Attorney agrees to be responsible for providing such notice. The parties agree that a photocopy of this Agreement shall be considered as valid as the original.
7. If Patient should retain new legal counsel, Attorney and Patient agree to notify Provider immediately upon such change. Patient shall direct such new legal counsel to execute another copy of this Agreement and deliver same to Provider.
8. This Agreement cannot be modified, amended or revoked by any party without the express written consent of all parties.
9. If the net recovery is less than the outstanding charges owed to all health care providers covered by letters of protection or lien rights, net settlement proceeds will be distributed on a pro rata basis or as required by legal priority under Georgia or other applicable law.

Acknowledgement by Patient
I acknowledge that this Agreement must be signed by myself and by my attorney before any medical services will be provided to me by Provider. I have been advised that if my attorney does not wish to cooperate in protecting Provider’s interest, Provider will await payment and may declare the entire balance due and payable.
(Patient’s Signature)

Date

Patient’s Printed Name:

TO PATIENT’S ATTORNEY: Please sign, date and return one copy of this Agreement to Erik Thor Bendiks MD PC DBA Georgia Spine and Orthopaedics. Keep one copy for your records.
Acknowledgement by Attorney
I acknowledge that this Agreement must be signed by representing attorney and patient before any medical services will be provided to me by Provider. I understand that if I do not wish to cooperate in protecting Provider’s interest, Provider will await payment and may declare the entire balance due and payable.
(Attorney’s Signature)

Date

Attorney’s Printed Name:

Attorney’s Address (Street, City, State and Zip Code)

New Patient Packet
PERSONAL INFORMATION

Patient Name: Date of Birth: Home Address: City: State:
Zip: Home Phone: Cell: Work: ext.
Email :
Sex: [radio* radio-350 "Male" "Female"] Marital Status: Work Status:
Employer: Occupation:
Employer Address:
Emergency Contact Name:
Emergency Contact Phone:

INSURANCE INFORMATION
Primary Insurance: Policy Holder:
Relationship to Policy Holder: Policy Holder DOB:
Secondary Insurance: Policy Holder:
Relationship to Policy Holder: Policy Holder DOB:

HIPAA ACKNOWLEDGEMENT

In accordance with the HIPAA of 1996, I acknowledge that I was given access to and/or offered a copy of the Notice of Privacy Practices for ERIK T BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS.

Patient Name: Legal Guardian:
Signature of Patient over 18 years old or Legal Guardian:

Date:

 
CONSENT For TREATMENT and ASSIGNMENT of BENEFITS
I consent to the provision of treatment that may include diagnostic procedures and medical treatment by ERIK T BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS. I understand special consent forms may need to be signed for specific procedures. If I have a religious objection to specific care to be provided, I may ask ERIK T BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS not to provide such care.

I consent to treatment by ERIK T BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS with the understanding that I will furnish accurate information regarding my injuries and will cooperate when referred to other physicians or medical facilities for examination or testing. My non-compliance with the plan of treatment may result in the refusal of further care and discharge from ERIK T BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS.

I acknowledge that no guarantees have been given to me as to the outcome of any examination or treatment. I hereby authorize Georgia Spine & Orthopaedics to leave medical information pertaining to my care by the following

I understand that my ability to receive medical care is not affected by the signing this form. I have the right to receive a copy of this form after it is signed. I may revoke this consent at any time in writing but revoking consent will not affect any actions prior to receiving the revocation.

This consent shall remain in effect until such written request to revoke is received.

I hereby give permission to allow GSO to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. By signing this consent, I give GSO permission to collect and give my pharmacy and health insurer permission to disclose information about my prescriptions that have been filled at any pharmacy or covered by any health plan. This includes prescriptions to treat AIDS/HIV and medications used to treat mental health issues.
Assignment of Benefits: Patient herby assigns and authorizes payment directly to GSO of
any private healthcare insurance, (ii) medical payment insurance, (iii) injury benefit due because of liability of a third-party, and (iv) proceeds of all claims resulting from the liability of a third party, payable by any party, organization, attorney, etc., to or for Patient, unless and until Patient’s account with GSO for the services or series of related services provided by the GSO Providers (collectively, the “Services”) is paid in full, upon discharge or completion of the Services. Patient herby authorizes GSO to apply and file for all such payments referenced herein on behalf of Patient, and direct that such payments be made directly to GSO.
Payment Responsibility: Patient understands that he/she is responsible for any portion of the GSO invoice(s) for Services that remains outstanding. Patient agrees to execute any necessary documents to direct all third-party benefits and other payments for Services to GSO.

THE INFORMATION I HAVE PROVIDED IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND ABILITY. I HAVE READ/COMPLETED OR HAVE HAD THIS ACKNOWLEDGEMENT AND CONSENT FORM READ/ COMPLETED FOR ME AND IT HAS BEEN EXPLAINED TO MY SATISFACTION AND APPLIES TO ALL ERIK T BENDIKS MD PC PROVIDERS.

Patient Name: Legal Guardian (if applicable):
Signature of Patient over 18 years old or Legal Guardian:

Date:
CONSENT TO MAIL MEDICATIONS TO MY HOME
GENERAL INFORMATION
Our medical practice is licensed to dispense certain medications (“Your Medications”). As a convenience to you, we are willing to mail you refills of Your Medications to your home address via First-Class Mail. There is a risk, however, that (i) someone may steal Your Medications out of your mailbox, (ii) a family member or other person authorized to collect the mail from your mailbox may wrongfully take Your Medications, (iii) Your Medications may get lost or stolen in transit from our office to your mailbox, or (iv) Your Medications may be delivered to the wrong address. Additionally, a collateral risk of mailing Your Medications is that your Protected Health Information (PHI) is discovered by an unauthorized party. Knowing these risks and accepting the liability and responsibility for same, if you still want Your Medications mailed to you, then you must complete this form to show that you have accepted this risk. Our office is not responsible if sending Your Medications results in an unauthorized person seeing your PHI or obtaining Your Medications.

ACCEPTANCE, CONSENT, AND WAIVER
This form gives you the facts about receiving Your Medications by mail. By signing this form, you confirm that you have read, understand, and agree with these terms.

I agree to allow Georgia Spine and Orthopedics of Atlanta and/or Surgery Center of Roswell (collectively, “GSO”) to mail my prescriptions directly to my address as listed below. This mailing will include my PHI, such as my name and the medication that I am taking and may include other sensitive facts about my health. I understand that if another person accesses my prescription, that person will see my PHI. If I do not want to accept the risk that someone may take my prescription and/or access my PHI, I should not agree to allow GSO to mail my prescriptions to me.

I accept these risks and agree that GSO may mail my prescriptions to me via First-Class Mail. I agree to inform GSO immediately if my address changes. I will not hold GSO responsible if my PHI is seen by an unauthorized person or my medications are taken/obtained by an unauthorized party. I RELEASE, WAIVE, DISCHARGE AND PROMISE NOT TO SUE OR BRING ANY CLAIM OF ANY TYPE AGAINST GSO FOR LOSS, DAMAGE, INJURY, OR LIABILITY RELATING TO THE MAILING OF MY MEDICATIONS TO MY DESIGNATED ADDRESS.

My designated address and the address where I hereby request GSO to mail my prescriptions is:

PATIENT ACKNOWLEDGMENT
This form gives you the facts about and risks involved in receiving Your Medications by mail. By signing this form, you confirm that you have read, understand, and agree with these Terms of Use for receiving Your Medications by mail.
My signature below indicates that I freely consent to receive my medications from GSO by mail to the address that I provided herein. I also confirm by signing below that:
• I have been able to ask any questions
• All my questions have been answered
• No guarantees have been made
• I agree to the terms as noted above
By my signature below, I acknowledge having the choice between obtaining my medications from GSO or at a pharmacy of my choice and authorize Comprehensive RX the right to my medical records upon verbal or written request.

Patient Name and Date of Birth:

Signature of Participant or Responsible Party:

Date and Time: Relationship to Patient:

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