For a printable version please visit: https://bluestonemd.com/resources/enrollment-forms/

I understand that a patient may voluntarily designate or appoint an individual other than the patient to make medical decisions on the patient’s behalf. The individual may be referenced on the applicable authorizing paperwork using the following terms or other similar terms: Power of Attorney, Healthcare Surrogate, Healthcare Proxy, Healthcare Power of Attorney, Guardian, etc. (collectively referred to here as the “Legal Representative”). I acknowledge and agree that by signing this form as Legal Representative, I swear and attest that I am legally authorized to act and make decisions on the patient’s behalf. I am required to provide a copy of valid and effective documentation outlining my role as Legal Representative in order to receive related communications, including verbally and via the Bridge. The Bridge is where you can electronically contact Bluestone’s care team 24 hours a day, 7 days a week for questions, and is where the care team will connect with you about the patient’s care. Upon signing this form or any other required documentation from Bluestone as a Legal Representative for the patient, I hereby release and hold harmless Bluestone Physician Services and its representatives from any claims or damages arising from Bluestone’s reliance on my attestation that I am the patient’s Legal Representative. If there is a/you are the Legal Representative, please provide their/your contact information below:

Release Information To:

Bluestone Physician Services
Attn: Medical Records Dept.
270 Main Street N., Suite 300
Stillwater, MN 55082

FAX: 855-490-4045 PHONE: 877-599-1039

This authorization is intended to provide my health care providers with the written authorization necessary to allow each of them to disclose
my individually identifiable health information regarding my health or medical records to Bluestone Physician Services. I hereby release my
expectation of privacy in such situations and agree to hold harmless any covered entity that acts in reliance on this authorization

I hereby authorize the release of my individually identifiable health information described above for treatment and payment purposes. I understand that this authorization to release health information is voluntary. I understand that the information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by federal or state law.

I acknowledge and agree that by signing this form as a Legal Representative for the patient, I swear and attest that I am legally authorized to act and make decisions on behalf of the patient. I am required to provide a copy of valid and effective documentation outlining my role as Legal Representative in order to receive related communications. Upon signing the form or any other required documentation from Bluestone as a Legal Representative for the patient, I hereby release and hold harmless Bluestone Physician Services and its representatives from any claims or damages arising from Bluestone’s reliance on my attestation that I am Legal Representative.

Need to authorize health information from another clinic? Please click this link for an additional form.

Authorization for Release of Health Information

Consent for Services and Disclosure of Information for Treatment: I consent to any and all medical evaluation and treatment, preventative care services and procedures which are deemed necessary or advisable by Bluestone medical providers and designees. I consent to the use of telemedicine services in the course of my diagnosis and treatment with my Bluestone Provider Team. Telemedicine involves the use of audio, video or other electronic communications to interact and consult with the healthcare provider(s). I also consent to the use and disclosure of my health information by Bluestone for my treatment, including disclosure of my health care information to health care providers and facilities unrelated to Bluestone that may be involved in care

Health Information Exchange: Bluestone may disclose my health information to and access my health information from other providers using a record locator service or patient information service of a health information exchange unless I object by checking below:

Acknowledgement of Receipt of Notice of Privacy Practices (NPP): The privacy of your protected health information is important to us. We have provided you with a copy of our Notice of Privacy Practices. It describes how your health information will be handled in various situations. We ask that you sign this form to acknowledge you received a copy of our Notice of Privacy Practices. This includes the situation where your first date of service occurred electronically. I have received Bluestone Physician Services, P.A., Bluestone National, LLC, and Bluestone Physician Services Wisconsin, and its subsidiaries and affiliates, (collectively, Bluestone Physician Services (BPS) Privacy Notice.

Patient Financial Consent: I understand that it is my responsibility to know what the terms of my insurance are, and in compliance with those terms, I understand I will pay all applicable co-pays or co-insurance and outstanding account balances as they become due. I understand that it is my responsibility to read and review the Bluestone Physician Services (BPS) Patient Financial Consent policy located online at BluestoneMD.com and agree to be bound by its terms.

Guiding an Improved Dementia Experience (GUIDE): Certain Medicare beneficiaries qualify for enrollment into the GUIDE program which is designed to support people with dementia by providing additional resources for their care with no cost sharing. I understand that Bluestone is required to submit my information to Medicare to verify eligibility and to be enrolled into the program. I understand I will not be enrolled until my care team has requested my consent. I give Bluestone permission to enroll me in GUIDE unless I decline. I understand my care plan will be available on the patient portal and that more information concerning this program is available on the website.

Use of Health Care Records in Program Evaluations and Training: I give Bluestone permission to use and disclose information gathered during the course of my treatment from Bluestone, including information from my treatment records, for the purposes of program evaluation and training and for overall quality review, including staff performance and outcomes at Bluestone.

Advanced Primary Care Management (APCM): APCM includes services between visits to coordinate my chronic care needs. I understand that these services will be billed to my insurance on a monthly basis with normal cost sharing per my plan’s specifications. If I am a Qualified Medicare Beneficiary, I am not responsible for any
cost sharing. I understand that only one practitioner may furnish and be paid for APCM services during a given calendar month and that I have the right to stop APCM services at any time, effective at the end of the month. Information about this program is available on the Bluestone website. I understand I will not be enrolled until the billing provider has requested my consent. I give Bluestone permission to enroll me in APCM unless I decline. My APCM care plan will be
available on the patient portal.

Behavioral Health Integration Services (BHI): I give Bluestone permission to enroll me in BHI services when appropriate. I understand the billing provider will get my permission to consult with relevant specialists including a psychiatric consultation and that cost sharing applies for services even if insurers cover cost sharing.

Consent for Use of Medical Records in Academic Research: I authorize Bluestone Physician Services to use or disclose my health records for medical or academic research, including health records created at any time by Bluestone and records Bluestone received from other health care providers, unless I object by checking below:

AI Technology: I consent to the use of secure, HIPAA-compliant AI technology to capture and transcribe audio from my visit for the sole purpose of assisting with accurate clinical documentation.

If Legal Representative signing this form: I acknowledge and agree that by signing this form as a Legal Representative for the patient, I swear and attest that I am legally authorized to act and make decisions on behalf of the patient. I am required to provide a copy of valid and effective documentation outlining my role as
Legal Representative in order to receive related communications. Upon signing the form or any other required documentation from Bluestone as a Legal Representative for the patient, I hereby release and hold harmless Bluestone Physician Services and its representatives from any claims or damages arising from Bluestone’s reliance on my attestation that I am Legal Representative.

The Bridge and the Patient Portal are HIPAA compliant communication and health record systems where you and/or people you authorize can stay updated or access important health information online and access the Bluestone care team anytime. The Bluestone Bridge allows members of the patient’s care team to exchange medically relevant messages between regular visits. The Patient Portal is a separate platform allowing additional access to personal health information.

This consent applies to health information Bluestone already has about me, information about future care I may receive from Bluestone and information Bluestone receives from third parties. This consent will continue unless I cancel by giving written notice to Bluestone Physician Services or it expires as required by law. Cancellation will apply after the date when the notice to cancel is received. It will not affect information that used or disclosed before cancellation.

REQUIRED: By signing this form, you acknowledge the information provided herein and request access to the Bluestone Bridge and Bluestone Patient Portal for you or a legal representative as well as (optionally) an additional designated individual. Access to these systems includes patient Protected Health Information records as maintained by Bluestone Physician Services, including the ability to view updates on health care status and the ability to communicate with the assigned Bluestone care team.

If patient is signing this form: I can authorize a personal representative to access my health care information and communicate with my Bluestone Provider Team electronically through the Bluestone Bridge and/or the Bluestone Patient Portal by filling out the PHI form with the appropriate information.

If Legal Representative signing this form: I acknowledge and agree that by signing this form as a Legal Representative for the patient, I swear and attest that I am legally authorized to act and make decisions on behalf of the patient. I am required to provide a copy of valid and effective documentation outlining my role as
Legal Representative in order to receive related communications. Upon signing the form or any other required documentation from Bluestone as a Legal Representative for the patient, I hereby release and hold harmless Bluestone Physician Services and its representatives from any claims or damages arising from Bluestone’s reliance on my attestation that I am Legal Representative.