COVID-19 Test Registration

Name of pharmacy and closest major intersection
I certify that I have been made aware of Summit Health Pointe Notice of Privacy Practices and that I have a right to receive a copy upon request. This Notice describes the type of uses and disclosures of my protected health information that might occur during my treatment, to facilitate the payment of my bills or in the performance of Summit Health Pointe health care operations. The Notice also describes my rights and the duties of Summit Health Pointe with respect to my protected health information. I understand that copies of the Notice of Privacy Practices are available in the registration areas of each facility and on Summit Health Pointe website at I may request that a copy be mailed to me by calling 586-598-8115. Summit Health Pointe reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the above number and requesting a revised copy be mailed to me, by asking for one at the time of my next appointment, or by accessing Summit Health Pointe website listed above to view the most current version. By signing, you agree that you have received and reviewed the Notice of Privacy Practices (HIPPA and Your Privacy Rights). By signing, you also agree that you have received and reviewed the Authorization For Claims Payment and Reviews form. I. Assignment and Coordination of Insurance Benefits - I agree to provide information regarding hospitalization, health maintenance organization, Workers' Compensation and other health care benefits ("Insurance Plan(s)") to which I may be entitled. I hereby assign payment(s), if any, from my Insurance Plan(s) to Summit Health Pointe (or its affiliate) and each of the independent contractor physicians and/or professional corporations for services rendered to me. The direct payment hereby assigned and authorized includes any Insurance Plan(s) benefits to which I am otherwise entitled, including any major medical benefits otherwise payable to me under the terms of my policy, but is not to exceed the balance due to Summit Health Pointe (or its affiliate), the independent contractor physicians and/or professional corporations for services rendered to me during the periods of medical care. By signing, I certify I have read and understand and have had the opportunity to ask questions and have them answered (the above conditions and terms and I agree to pay all charges for which I may be legally responsible including, but not limited to health insurance deductibles, co-payments. I also agree in the event my account must be placed with an attorney or collection agency to obtain payment, I will pay the attorneys· fees and other collection costs incurred by Summit Health Pointe. I understand and agree this document will remain in effect for all future outpatient or physician office visits to Summit Health Pointe. unless specifically rescinded in writing by the owner the the clinic. By signing this form you agree that in the event you are not satisfied with our services and your care you will not post online comments to that effect. *