Forms Once you have made the decision to make ISCA a part of your action strategy, we require that you fill out some forms: a Disclaimer/release form, an Escrow Account Form, a Client Enrollment Health Form, and an Authorization for Disclosure of Health Information.
The Disclaimer/Release Form
The ISCA Disclaimer/Release Form provides us with contact information, and also gives us your signed authorization to obtain information from the institutions, doctors and other medical entities that are, or have been, associated with your case in the past. The disclaimer is so you understand that while we will do our utmost to bring you to the forefront of the latest diagnostic testing and treatments, we cannot guarantee that you will overcome your disease.
The Escrow Account Form
The ISCA Escrow Form is required in order to establish an escrow account for your deposit. Unfortunately, some of the critical diagnostic tests, and even some treatments, are not yet covered by insurance. The money you deposit is a spend-down account for those tests or services that are not covered by medical insurance. This fund is also established to cover services provided by ISCA. Your account will be set up at the PNC Bank in Kennett Square, PA. When we send you the Escrow Form we will also send you information about PNC Bank.
The Client Enrollment Health Form
The Client Enrollment Health Form will give us a general idea of your past and present health issues and give us the contact information we will need to access your medical information.
Authorization for Disclosure of Health Information Form
In order to maintain the client's privacy, ISCA will not release personal health information without receiving prior authorization from you in writing. It is necessary for ISCA to obtain written authorization prior to the release occurring. Therefore, we require you to fill out the Authorization for Disclosure of Health Information form.