TELEHEATH CONSENT FOR TREATMENT
I consent to completing an in-person or virtual/telephonic evaluation with a licensed medical provider who will conduct an assessment and answer any questions I may have.
I acknowledge that no guarantees have been made as to the effect of any treatment.
FINANCIAL RESPONSIBILITY AGREEMENT
I acknowledge full financial responsibility for any service rendered and I understand that the payment of charges incurred is due at the time of service.
HIPAA Privacy Notice
We and our affiliates, employees and agents, may use and disclose protected health information (e.g., information relating to the diagnosis, treatment or billing which identifies patient's name, address, social security number) for the purpose of your treatment and share your PHI with other providers involved in your care.
We use SureScripts, Inc., a system that allows prescriptions and related information to be exchanged between our providers and the pharmacy. The information sent between these systems may include details of any and all prescription drugs taken currently and/or in the past..
We may use and disclose PHI to help resolve insurance claims and health benefit coverage issues such as prior authorizations of medications, specialist referrals etc...
We may use and disclose PHI to support our Healthcare operations. These activities include but are not limited to performance reviews, employee training and quality assessment tasks. For example we use sign-in sheet where you are asked to leave your first name and we may also call you by your name in the waiting room our staff is ready for you.
We may disclose PHI when required by the law for public health purposes such as mandatory reporting of communicable disease, abuse and neglect etc...
You may refuse to sign this notice. Your refusal to sign will not affect your eligibility for benefits or enrollment or payment for or coverage of services.