Annual Patient Consent for Release of Information and Medical Claims Processing

I. Consent to Treat

I understand and agree that:

• I am giving voluntarily consent to receive medical evaluation, treatment, and related healthcare services provided by the physicians, advanced practice providers, nurses, and staff of Pioneer Physicians Network, Inc. (“Pioneer”). This includes routine diagnostic tests, immunizations, laboratory draws, examinations, and minor office procedures.
• Healthcare may involve risks and benefits, and no outcomes are guaranteed.
• I may be seen by covering providers, including physicians and advanced practice providers, as needed.
• I will participate in my care by following agreed-upon treatment plans and to communicate respectfully with Pioneer staff and providers.
• I may refuse treatment, request additional information, or withdraw my consent in writing at any time.

II. Financial Responsibility

I understand and agree that:

• I am financially responsible for all charges resulting from services provided, regardless of insurance coverage.
• Co-pays, deductibles, and co-insurance are due at the time of service. Accepted forms of payment include exact cash, checks, credit/debit cards, and HSA/FSA cards. Refunds are not returned to the original method of payment. I understand that I will receive any refund via a virtual credit card; however, I may request to receive a physical credit card or paper check instead.
• I will be asked for payment on outstanding balances when I arrive for my visit. One time statements are mailed out for balances under $20.
• My balance is due in full upon receipt of the monthly statement, which includes co insurance, deductibles, non-covered services, and any denied claims the billing department was unable to resolve with my insurance company. I will be responsible for working with my health insurance company should they request additional information from me for claim payment.
• I must provide accurate and up-to-date insurance information. If Pioneer cannot process my claim due to delays or errors, I will be responsible for payment and will need to submit a claim for reimbursement directly with my insurance provider.
• If I have a High-Deductible Health Plan (HDHP), I may be required to make an upfront payment of $125 until my deductible is met. The payment may be adjusted based on the level of service to be provided.
• If I do not have insurance, payment is due at the time of service, and a driver’s license or other identification will be required. A 20% discount on all office-based services, excluding vaccines and vaccine administrations, and a 40% discount on all laboratory services will be applied for same-day payments in full.
• Worker’s Compensation, Motor Vehicle Accident, and ODOT physicals require special processing and may be treated as self-pay if proper documentation is not provided. Not all physicians are BWC providers, and Pioneer will not process claims to auto insurance carriers.
• Returned checks are subject to a $25 fee, and Pioneer will not accept another personal check until fees are paid. After two NSF returned checks, Pioneer will no longer accept personal checks.
• Balances not paid in full upon receipt of statements may be referred to collections, which may impact my ability to continue receiving services at Pioneer. I am responsible for any legal or collection fees incurred.
• A $50 no-show fee may be charged for missed appointments without at least 24 hours’ notice.
• Pioneer will work with me in good faith to resolve billing issues or set up payment arrangements if I contact the billing department.

III. Assignment of Benefits & Release of Information

I authorize:

• Direct payment of medical benefits from my insurance company to Pioneer Physicians Network, Inc.
• Pioneer to release any medical information necessary to process my claims, including electronic and facsimile transmission.
• Use and disclosure of my medical information for purposes of treatment, payment, and healthcare operations, in accordance with Pioneer’s Notice of Privacy Practices.
• The electronic transmission of prescriptions to my pharmacy, and coordination of formulary and benefits eligibility with my insurer.
• Pioneer to query my external prescription history as necessary for safe and effective care.

IV. Notice of Privacy Practices (NPP) Acknowledgment

I acknowledge that I have received or been offered a copy of Pioneer Physicians Network’s NPP, which describes how my medical information may be used and disclosed.

V. Communication & Telehealth Consent

I understand and agree that:

• I am giving consent to receive medical services through telemedicine (audio, video, and/or other digital means) in accordance with Pioneer Physicians Network’s telehealth policies and applicable laws, including the Health Insurance Portability and Accountability Act (HIPAA).
• Electronic communications with my care team, including, but not limited to, e-visits, portal messages, or other digital medical advice requests, may constitute billable services under certain circumstances.
• Such services may be subject to applicable copayments, coinsurance, or deductibles as determined by my
  insurance plan or self-pay agreement.

VI. Ambient Listening, AI Documentation, and Scribe Use

• I understand that Pioneer Physicians Network may use ambient listening, artificial-intelligence–assisted technologies, and in-person or virtual medical scribes during my visits to support clinical documentation and improve care quality. These tools and services are used within Pioneer’s HIPAA-compliant environment and follow all privacy and security safeguards required by law.
• These tools and scribes may capture and analyze spoken words between me and my care team in real time for the purpose of generating accurate medical documentation or clinical summaries.
• I acknowledge that any information processed or accessed by these technologies or scribes is protected under applicable privacy laws and will be used only for authorized treatment and healthcare operations.
• I may request that these technologies or scribe services not be used during my visit, and my request will not affect my access to care.

VII. Emergency Treatment & Advance Directives

I understand and agree that:

• I am giving consent to Pioneer providing emergency treatment in the event of an unexpected reaction or urgent need while in the office.
• I may provide an Advance Directive, Living Will, or Healthcare Power of Attorney to be kept on file, and it is my responsibility to keep this information current.

• By signing below, I acknowledge that I have read, understand, and agree to this Annual Consent to Treat, Financial Responsibility Agreement, and Assignment of Benefits & Release of Information.
• I understand this consent is valid for one year from the date signed unless revoked in writing. Revocation does not apply to information already released or claims already processed.