warning

Alert: Because flu cases are on the rise, children 12 and younger will be restricted from visiting hospitals and certain inpatient facilities. Learn more.

When you come for care, you will sign several forms that let us help you. The three forms are on the computer, but you can ask for a copy of the forms to read before you sign. This page will tell you about each form and what it covers.

  1. Request for Treatment and Authorization Form

    When you sign this first form, you agree to these things:
    • Request for Treatment
      You agree to let the healthcare team take care of you. We can do this in person or by telemedicine.
    • Assignment of Insurance Benefits
      You agree to let us send bills to your insurance and get paid directly from them. This can be a private health plan, Medicaid or Medicare. You pay for any care not paid by your insurance.
    • Notice of Independent Contractors
      This reminds you that Carolinas HealthCare System uses some non-Carolinas HealthCare System providers for care, like when you receive anesthesia or X-rays. You may get a separate bill from them.
    • Release of Medical Information
      You understand that we will share your health records with your healthcare team. We will also share your information with your insurance, as needed to pay for your care.
    • Authorization to Release Medicare and Medicaid Information
      You agree to have your records reviewed to see if they meet the rules of Medicaid or Medicare. We will then send bills and get paid directly from them.
    • Payment Guaranty
      You agree to pay any bills not paid by your insurance. Collection agencies chosen by Carolinas HealthCare System can call you about any bills you have not paid.
    • Personal Property
      This reminds you that the hospital will hold any money or belongings for you until you leave. They are not responsible for any belongings in your room.
    • Appointment and Release for Financial Purposes
      You agree to let Carolinas HealthCare System Financial Counseling department help you apply for Medical Assistance programs. These programs can help you pay for your medical bills.
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  3. Notice of Privacy Practices

    The second form you will sign is about privacy. Carolinas HealthCare System obeys the Health Insurance Portability and Accountability Act (HIPAA). The Notice of Privacy Practices brochure tells you how we protect your health data. It tells you what and who we share your data with and your rights under HIPAA. These brochures are at each place you may get care. You can have a copy of this brochure. You sign that you know how to get the brochure and how we protect your health data.
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  5. Insurance Verification Letter

    This is the last form you will sign. You agree that the insurance on the form is right. Insurance can be private, where you work, Medicaid or Medicare. If you do not have insurance, you will pay your health care bills. If you have Medicaid “Be Smart Family Planning,” you understand that it does not cover inpatient or emergency room visits. You will be billed for those. You agree to help us try to get coverage like Medicaid. If we don’t have the right insurance information, you will be billed for your healthcare.
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