I was offered a copy of the Rockingham County Health and Human Services Notice of Privacy Practices.

I give permission for Rockingham County Health and Human Services (RCHHS) to release any medical information which is requested by Medicaid, other insurance companies, or other agencies assisting in my care.

I give permission for my photo to be taken by camera or ID to be copied and used to identify me and assist in my care. This is for RCHHS’s use only and will not be released to any other source without my written permission.

I understand that I may receive emails, phone calls, or text appointment reminders.

I give permission for RCHHS to check income and insurance coverage through employers and/or other sources as necessary to determine my eligibility for services.

I understand that fees for services may be reduced upon verification of income eligibility. Also, I am aware that I am allowed ten (10) business days to submit my income verification.

I understand that I may receive services or be referred for services provided by other physicians, laboratories, hospitals, or other agencies. I understand fees that other agencies charge are my personal responsibility.

I understand that payment for services is expected at the time of service, as a courtesy. If I have Medicaid, Health Choice, or private dental insurance, RCHHS will bill them for my treatment.

I understand that if I have Medicaid and other dental insurance, Medicaid will pay after my other dental insurance pays.

I understand that Medicaid, Health Choice, and private dental insurances do not pay for every procedure I may need. I am personally responsible for any part of my bill not covered by Medicaid or other dental insurances. I understand that I must pay my balance if my insurance does not pay in 60 days. I am aware that, if I have questions or concerns with what my insurance plan covers or pays, I can talk with my insurance company.

I understand in the event RCHHS fails to bill for a procedure that was performed they will bill me or my third party payor.

I understand that if outstanding balances remain unpaid, RCHHS has the right, unless restricted by State or Federal regulations, to refuse or deny further services to me.

I request that Medicaid or other insurance payments for services received through RCHHS are to be paid directly to RCHHS. I agree to pay RCHHS any money that I receive from any source that is sent directly to me as payment for services that I have received from RCHHS. I will make this payment within 45 days of the day that I receive this money.

I will notify RCHHS of any changes in my income, insurance, address, and phone number for program services.

I understand that this consent is valid for one year unless I revoke it in writing.

My signature acknowledges that no guarantees or warranties have been made to me concerning the results of the examinations, treatments, or procedures and I have been given the opportunity to ask questions about this consent form and the opportunity to refuse services for me or as the verified personal representative of the individual named above.