As you are aware, healthcare in the United States is currently undergoing many changes. As a result, insurance carriers are becoming more selective in terms of what they deem "necessary care" or "covered care". At Arrowhead Health we believe preventive care is essential to your health and therefore will continue to offer a thorough evaluation to every one of our patients.

Although we try hard, it is not always possible to verify all the terms of every patient's insurance plan to determine if preventive care is a covered benefit. We are informing you in advance that some tests and/or procedures, although constituting good medical care, may be considered as screening or preventive in nature by some insurance companies, and thus not covered. This testing will be your financial obligation if denied by your insurance carrier. We advise that all of our patients review their insurance benefit coverage. We will continue to do what we can to help in this respect.

Please list the insurance companies that you will be using for services at Arrowhead Health:

I, the undersigned, certify that I (or my dependent) have insurance coverage with the insurance company(ies) listed above and assign directly to Arrowhead Health all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance, and that it is my sole responsibility to understand the insurance benefits that apply. I authorize the use of this signature on all insurance submissions.

I hereby give my consent for Arrowhead Health to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Arrowhead Health describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. Arrowhead Health reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to:

Arrowhead Family Health Center, P.C.  d.b.a.  Arrowhead Health
16222 North 59th Avenue,
Glendale - 85306 AZ



With this consent, Arrowhead Health may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Arrowhead Health may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.

With this consent, Arrowhead Health may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Arrowhead Health restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow Arrowhead Health to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.