Patient Consent & Financial Policies

Use and Disclosure of Protected Health Information

I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services, my private insurance, and their agents any protected health information (PHI) or individually identifiable health information (IIHI) needed to determine benefits for related healthcare services.

Patients are directed to review TRS Health's Notice of Privacy Practices for complete details on uses and disclosures, with the right to review this document prior to signing consent.

Consent to Bill, Assignment of Benefits, and Payment

I authorize TRS Health to submit claims to my insurance carrier for the medical services provided by TRS Health. My insurance company, in lieu of reimbursing me directly, will pay to TRS Health any benefits for services rendered.

Billing amounts reflect standard contracted rates between TRS Health and insurance carriers. I agree to cover services not covered by my insurance, including copayments, coinsurance, deductibles, and non-covered charges.

Financial Assistance

For patients with financial need, we offer extended payment plans or financial assistance programs. Patients are encouraged to consult our Patient Care Specialists about available options at (281) 385-8554.

Assignment of Benefits

I understand that TRS Health reserves the right to review all agreements on an individual basis to determine continued acceptance of assignment for Medicare and/or other insurance providers.

Acknowledgments

By signing, I acknowledge that I have received the Patient Bill of Rights and Notice of Privacy Practices, available at trshealth.org. I consent to TRS Health contacting me regarding appointments or follow-up care.

Revocation

I understand that I may revoke this consent in writing; however, my revocation will not apply to information already used or disclosed in reliance on this consent.

A representative may sign on behalf of a patient unable to do so, with documented details required.

Questions?