Patient Signature Forms

Provider-Patient Arbitration Agreement

March 2020

Article 1: Agreement to Arbitrate

Despite best efforts, a dispute may arise as between a Patient and DRC 360, LLC (the “Practice”). In the event Patient has any dispute with the Practice, employees, agents, and/or providers (collectively referred to as “Practice”), a claim for such a dispute will be arbitrated. This essentially means that the claim will not be filed as a lawsuit in a Court of law. Both parties to this Agreement, by entering into it, are knowingly giving up their constitutional right to have any such claim decided in a court of law, before a jury, or administrative proceeding, and instead are accepting the exclusive use of arbitration. The Practice believes that by entering into this Arbitration Agreement, disputes can be resolved in a faster and more cost-efficient way for both the Patient and the Practice and that both Parties are thus better served. However, the signing of this Agreement is not mandatory and is NOT a condition to being provided medical services. It is simply an offer of means to resolve any issues that may arise between you and the Practice.

Article 2: All Claims Must Be Arbitrated:

Both the Practice and Patient intend for arbitration to be the exclusive resolution process for all disputes arising out of the provider-patient relationship including, but not limited to, disputes related to treatment, medical negligence, unnecessary services, unauthorized services being performed, privacy matters, communications, other statutory rights or any other claim against the Practice. This includes claims which may be made by Patient, Patient’s estate, Patient’s representative, or Patient’s family on behalf of the Patient against the Practice.

Article 3: Arbitration Process

In order to begin the arbitration process, Patient must provide the Practice with a written notice of the claims(s). The notice shall describe the nature of the controversy and the remedy sought. Then, within sixty (60) days, the Practice and the Patient will work together to select a mutually agreeable certified arbitrator located in Union County, New Jersey. If they cannot agree on an arbitrator, both the Practice and Patient will each select an individual to serve as an arbitrator, and the two arbitrators will then jointly select a neutral third arbitrator within thirty (30) days who will serve as the sole Arbitrator by dismissing the two original arbitrators. All notices under this Agreement shall be sent by the Practice and Patient and the arbitrator by Certified Mail with Return Receipt Requested or by overnight carrier with tracking.

The Practice shall pay the fees and expenses of the Arbitrator selected by the Practice. Patient shall pay the fees and expenses of the Arbitrator selected by or on behalf of Patient. The Practice and Patient shall equally pay the fees and expenses of the arbitrator ultimately selected as the neutral Arbitrator; but those expenses shall not include attorney fees or witness fees or other expenses incurred by the Practice or Patient for the benefit of the Practice or Patient, as each Party will be responsible for its own legal fees and costs.

The Practice and Patient agree that the arbitrators shall have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this Agreement.

The Practice and Patient have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator (or Arbitration Panel).

The Practice and Patient agree that the law of the State of New Jersey applicable to health care providers shall apply to all disputes within this Arbitration Agreement. Both the Practice and Patient may bring before the Arbitrators a Motion for Summary Judgment. Both the Practice and Patient may conduct discovery and take depositions without the approval of the arbitrators.

All Patient claims that are based on the same course of treatment or services rendered by the Practice shall be arbitrated in one arbitration proceeding. Patient claims shall be forever barred if they would have been barred, under the laws of the State of New Jersey, on the date the Practice is notified of the claim by Patient or if Patient fails to pursue the claim in compliance with the provisions of this Arbitration Agreement with reasonable diligence.

This Agreement may be revoked by written notice delivered to the Practice by Certified Mail with Return Receipt Requested or Registered Mail within thirty (30) days from the date this Agreement is signed by the Patient. However, any claims that arose during the effective time of this Agreement must be arbitrated in accordance with hereto. If not revoked, this Agreement shall govern all services received by the Patient.

It is the intent of this Agreement to include all services rendered to the Patient by the Practice at any time for any condition.

It is the intent of this Agreement that the decision of the Arbitrator as to any dispute arbitrated shall be a full final complete and legally enforceable decision. The arbitration decision shall be sent by Certified or Registered Mail by the Arbitrator to the Practice and to the Patient.

For any matter expressed or not expressed in this Agreement, the arbitrators shall be governed by the laws of the State of New Jersey relating to arbitration.

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Provider and Patient acknowledge each had the opportunity to consult with independent legal counsel concerning this Agreement and to review this Agreement in detail with counsel, regardless of whether the Patient actually does so.

The Practice and Patient, or Patient’s qualified representative, agree to this Physician-Patient Arbitration Agreement, and Patient has received a copy signed by Physician, or his authorized representative 


DRC360 Cancellation Policy/No Show Policy

General Appointments

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting the desired treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book.

If an appointment is not canceled at least 24 hours in advance you will be charged a fifty dollar ($50) fee; this will not be covered by your insurance company.

Surgery Appointments

Due to the large block of time needed for surgical procedures, last-minute cancellations can cause problems and added expenses for the office.

If a surgical procedure is not canceled at least 10 days in advance you will be charged a one-hundred-dollar ($100) fee; this is will not be covered by your insurance company.

Scheduled Appointments

We understand that delays can happen however we must try to keep the other patients and practitioners on time.

If a patient is 15 minutes past their scheduled time, we reserve the right to reschedule the appointment.

Account Balances

We will require that patients with self-pay balances do pay their account balances to zero (0) prior to receiving further services by our practice.

Patients who have questions about their bills or who would like to discuss a payment plan option may call and ask to speak to a business office representative with whom they can review their account and concerns.

Patients with balances over $100 must make payment arrangements prior to future appointments being made.

HIPAA Record Request & Production Policy


This policy outlines the protocol to follow when DRC360 (the “Practice”) receives a request from an individual patient, or directly on behalf of an individual patient, for records containing protected health information (“PHI”) and the applicable fee schedule to produce such records.

This Policy and the fees outlined herein does NOT apply to attorneys who are seeking records. Those requests will be handled on a case by case basis, and are subject to a surcharge at the sole discretion of Management.

Policy Elements

The Practice maintains records in electronic format. The Practice charges a reasonable, cost-based fee for individuals (or their personal representatives) to receive (or direct to a third party) a copy of the individual’s PHI. The fee is calculated pursuant to the HIPAA Privacy Rule, 45 CFR 164.524(c)(4), based on labor, supply and postage costs. The Practice will provide the individual with the PHI in the form and format and manner requested, if readily producible in that way, or as otherwise agreed to by the individual. A summary or explanation of the record can be prepared upon an individual’s request at an extra cost. The Practice will inform the individual in advance of the approximate fee that may be charged for providing the copy requested.

Calculation of Fees

Fees for generating copies of the PHI maintained electronically at the individual’s request will be calculated based on actual cost to fulfill the request.
The fee charged will be calculated based upon
1. the time needed to fulfill the request at the hourly rate of the staff person generating the copies, whether in paper or electronic format;
2. the time taken to fulfill the request at the hourly rate of the staff person preparing the summary or explanation, if requested by the individual;
3. plus the cost of supplies and postage to fulfill the request.

Financial & Payment Policy

Thank you for choosing our Practice as your primary care provider. We are committed to providing you with quality health care and have established a fee structure that is reasonable and customary for the geographic area we serve. We have developed this document for all of our patients to understand our financial/payment policies, and to demonstrate that you agree to abide by the same.

1. Insurance. We participate in most insurance plans, including Medicare. If we do not participate in your insurance plan, payment in full is expected at each visit. Please visit our website to see the health benefit plans in which the health care professionals at the Practice are participating providers and the facilities in which the health care professionals are affiliated. An estimated amount that the Practice will bill you for health care services is available upon request. It is your responsibility to determine what services are covered and in what amount, and although we will assist you in estimating your responsibility, we cannot guarantee what your insurance will ultimately pay. Please contact your insurance company with any questions you may have regarding your coverage. You will be responsible for any balance.

2. Co-payments, Co-insurance payments, and deductibles. All co-payments and coinsurances must be paid at the time of service, as required in your contract with your insurance company. Failure to collect these can be considered a violation of healthcare laws on the part of the Practice, and therefore we appreciate your cooperation in being prepared to pay these at the time of each visit. If you have difficulty making these payments due to financial hardship, please speak with the office manager who will provide you a form to request a waiver based on documented financial hardship.

3. Non-covered services. Please be aware that some and perhaps all of the services you receive may not be covered by your insurance provider. If the Practice is aware of this prior to the rendering of services, this will be discussed with you, and you must pay for these services in full at the time of the visit. If payment for services is denied for any reason whatsoever, you will be responsible to pay for the services as soon as you are notified that your insurance company has denied payment.

4. Proof of Insurance. All patients must complete our patient information form before being seen at the Practice. You must present your driver's license and current valid insurance card at each visit. If you fail to provide us with correct insurance information in a timely manner, and the claim for services is denied, you will be responsible to pay for the services.

5. Medicare. The Practice is a Medicare participating provider. Medicare or secondary carriers do not cover some procedures and supplies. Please make certain you understand which aspects of your treatment are covered before proceeding. You understand that you will be responsible for your annual deductible, the co-payment, and any non-covered services specified by Medicare. We may submit a claim to any supplemental plan as a courtesy to you, so long as you provide all necessary policy information.

6. Medicaid. If you are a Medicaid patient, you must present a valid eligibility card at the time of registration and prior to the time of service. Your eligibility status will be verified monthly. Without verification of coverage, you will be responsible for the full/entire balance of your account. As a courtesy to you, your account will be billed to Medicaid when we receive all necessary information. You are responsible for non-covered portions and spend-down requirements associated with your individual coverage. If at any time you are not eligible for Medicaid coverage and wish to be seen, you will be treated as a self-pay patient and must make payment at the time of service.

7. Claims submission. We will submit your claims and reasonably assist you to get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract, and therefore we do not assume risk of not being paid.

8. Coverage changes. If your insurance coverage changes, you must notify us before your next visit so we can make the appropriate changes to our records.

9. Nonpayment. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency.

10. Missed appointments. We expect that if you must cancel our appointment, you will do so with at least 24-hour’s notice. If you do not, you may be charged a fee as set forth in our Cancellation Policy.

11. Partial Payments. If you require a payment arrangement for any product, you must discuss this with the Office Manager who will determine if such an arrangement is appropriate, and you must authorize regular payments to a credit card maintained on file.

Out of Network Disclosure and Billing Policy


This policy outlines DRC360’s (the “Practice”) policy to provide patients with notice that the Practice is out of network with ALL insurance plans.

Policy Elements

1. Prior to non-emergency services being performed, the Practice will disclose through its internet website that the Practice is NOT a participating provider with any health benefit plan and disclose the facilities in which it is affiliated. These same disclosures will again be made, either verbally or in writing, at the time of an appointment.

2. At the time an appointment is scheduled, the Practice will inform the patient

a. that the Practice and Dr. Cavazos is out of network and that the amount or estimated amount for the services is available upon request.

b. upon request, in writing, the amount or estimated amount that will be billed to the patient, absent unforeseen medical circumstances that may arise, and the CPT codes associated with that service.

c. that the patient will have a financial responsibility applicable to health care services provided by an out of network provider.

d. to contact his/her insurance carrier for further consultation on those costs.

3. The Practice will notify a patient with respect to any additional health care providers be scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services in connection with care to be provided by the Practice, or whose services will be arranged by the Practice and are scheduled at the time of pre-admission, testing, registration or admission.
a. In such an event, the Practice shall provide instructions or information as to how to determine the health benefits plans in which the health care provider(s) participates and recommend that the patient contact the insurance carrier for further consultation on costs associated with these services.

4. If the Practice provides a patient emergency and urgent services, the Practice will not bill the patient in excess of any deductible, copayment, or coinsurance amount.

Patient Financial Responsibility Form

Thank you for choosing DRC360 (the “Practice”) as your healthcare provider. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.

Out of Network Disclosure

▪ DRC360 is an Out of Network Provider

▪ The amount or estimated amount for the services is available upon request.

▪ Upon request the amount or estimated amount that will be billed to the patient, absent unforeseen medical circumstances that may arise, and the CPT codes associated with that service, can be provided to you in writing.

▪ The patient should contact his/her insurance carrier for further consultation on costs

Patient Financial Responsibilities

▪ The patient (or patient’s guardian, if a minor) is ultimately responsible for the payment for treatment and care.

▪ Co-insurance, deductibles, and non-covered items are due 30 days from receipt of billing.

▪ Patients may incur, and are responsible for payment of additional charges, if applicable. These charges may include:
o Charge for returned checks
o Charge for missed appointments without 24 hours’ notice
o By my signature below, I hereby authorize assignment of financial benefits directly to Colorectal Health Northwest, LLC and any associated healthcare entities for services rendered as allowable under standard third party contracts. I understand that I am financially responsible for charges not covered by this assignment.

DRC360 HIPAA Compliant Authorization for
Use/Disclosure of Information and Consent/Use of Photographs/Images

DRC360 is always pleased when patients are willing to communicate the stories, experiences, and information about their treatment received at DRC360. Sharing your story can help others who are interested in knowing more about the services provided by DRC360.

As a health care provider, DRC360 must protect the privacy of our patients.  When capturing images of patients, we are required under the Health Insurance Portability and Accountability Act (HIPAA) to obtain their permission to use the images by completing the Authorization form (below).  Ensuring that medical information is kept confidential is among our highest priorities. DRC360 seeks your consent to allow us to take and use photographic material of you in DRC360 internal and external communications, including medical and patient education information, promotional materials and distribute such materials in print and online (such as social media sites and DRC360’s website).

To ensure that DRC360 is acting in accordance with your wishes, and using your photograph/image with your authorization, we ask you to fill out and sign this form. DRC360 will keep a copy of your written permission on file.

I give my consent for DRC360 to take and make use of my photographic images in publications produced by or on behalf of DRC360. This permission extends both to electronic versions on the DRC360 websites, social media and other internet/electronic applications as well as to printed versions.

I am not required to sign this authorization. DRC360 does not condition treatment, payment, benefit eligibility, or enrollment activities on the signing of this form. I can request a copy of this authorization be mailed to me. I understand that I will not be entitled to any payment or other form of remuneration as a result of any use of any information and photographic material.

If I decide to sign this form, I have the right to request that photographing cease at any time. If not revoked/withdrawn by me, this authorization expires ten (10) years from the date that I sign it.

I am aware that my protected health information in the form of a photograph/image will exist forever in either a printed, and/or electronic version or other version as may develop over time and that once it is published or disclosed in any form it will continue to be used. I understand that photographic materials about me used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the federal regulations protecting privacy of an individual’s health information under HIPAA and other applicable federal and state law.

I have read, understand, and agree to the provisions of the forms presented above.

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Signature Certificate
Document name: Patient Signature Forms
lock iconUnique Document ID: 069e22a2b5ffbcce1dc6fe6241bfc7119c9f8b62
Timestamp Audit
November 27, 2020 4:06 pm EDTPatient Signature Forms Uploaded by Maka Cavazos - IP
November 27, 2020 4:54 pm EDTDr C - added by Maka Cavazos - as a CC'd Recipient Ip: