× Consent Form
NOTICE OF PRIVACY PRACTICES
I have reviewed the Notice of Privacy Practices as provided at registration and understand that I may request a copy of the policy at any time.
CONSENT FOR TREATMENT
I, the undersigned, consent to the care and treatment by the attending Physician, his/her associates or assistants and acknowledge that no guarantees have been made as to the effect of such treatment.
ELECTRONIC COMMUNICATION CONSENT
Text Message and Informed Consent: In order to enhance patients' care and experience, we may contact you after your visit in order to request feedback on your experience by phone call, SMS text message, e-mail, voice mail, or mobile application, some of which may be via automated means. By signing below, you understand and agree to be contacted in this manner with communications related to this visit, and any future visits. In the future, you may opt-out of receiving text messages by notifying us in writing (including responding via text message). Standard telephone minute and text charges may apply if we contact you. In addition, based on your feedback, we may anonymously identify statements or comments that might help other potential patients choose to receive their treatment with us. By checking the box below and signing this consent, you acknowledge and agree that these comments and/or statements may be used on an anonymous basis on our website only, purely for providing those who may view the website with objective reviews of our care.
Mobile Safety Tips: While we work hard to protect your information, remember that electronic communication is never 100% secure. It’s very unlikely, but information you send via text, email or mobile application, or that you leave on your mobile device, could be exposed to people other than your doctor. Here are a few safety tips to follow:
1. Use a password on your mobile device to prevent strangers from seeing what is on your phone.
2. Limit the amount of sensitive health information you send. You can always call your provider to discuss something private or sensitive.
3. If you are worried about those close to you seeing your messages, you can delete them from your email or messaging app. This won’t erase them completely, but will make it hard for others to see them.
I acknowledge that I have read and fully understand this consent form. I understand that by selecting no, I am selecting to not receive electronic communications. In addition, I recognize that by selecting no, that I may still receive electronic communications from the provider if required by federal, state, or local law. By signing below, I acknowledge that I have read and fully understand this consent form, including the risks associated with the communication of E-mail, SMS messages, and other forms of electronic communication; and I consent to the conditions and instructions outlined, as well as any other instructions that the Provider may impose to communicate through E-mail, SMS, and/or other forms of electronic communication.
I give permission to contact me using electronic communication.
My anonymous feedback may be used on your website.
FINANCIAL RESPONSIBILITY/ASSIGNMENT OF BENEFITS
I acknowledge full financial responsibility for any services rendered and I understand that the payment of charges incurred by this practice are due at the time of service. I also understand that the charges not covered by insurance remain my responsibility and assign insurance benefits to this office. In the event my account is turned over to a collection agency, I agree to pay all costs of collection fees and/or attorney's fees and all court costs if any. I agree to be contacted at any telephone number or email address associated with my account. This includes cellular telephone numbers or other wireless devices. I understand this could result in a charge from my phone or device carrier to me for talk time, SMS messaging/texts or data usage for emails or voice mails. I also understand methods of contact may include pre-recorded /artificial voice messages and/or the use of automatic dialing devices as applicable.
CREDIT CARD ON FILE CONSENT
I authorize AFC Urgent Care (Woodruff Road Urgent Care Center, P.C. (the P.C.)) to keep my credit card, debit card or health care savings card on file and to charge my card for amounts determined by my insurance carrier to be my responsibility, or if my insurance claim is denied, all amounts that AFC Urgent Care (the P.C.) is authorized by law to bill me.
After receipt of an Explanation of Benefits (EOB) from my insurance carrier, any unpaid portion of my claim may be charged to my card, up to the pre-authorized amount. I understand AFC Urgent Care (the P.C.) will send me one statement for my review with a reminder that the charge to my card will be processed no sooner than three days after the date of the statement. I authorize AFC Urgent Care (the P.C.) to keep my signature on file and to charge my card for any balance owed by me, the patient (or the patient’s guarantor), not to exceed $150 per month without prior verbal authorization.
All payment card information will remain absolutely confidential and securely protected by Elavon, part of US Bancorp, a global leader in financial transaction processing. AFC Urgent Care (the P.C.) will not store any banking account data on our system.
I assign my insurance benefits to the provider listed above. I understand this agreement is valid for one year and will automatically renew annually unless this authorization is cancelled through written notice to AFC Urgent Care (the P.C).
PATIENT PORTAL CONSENT
The patient portal is an internet-based tool that allows our patients to view and access their health records. The patient portal may not contain a complete copy of your health records at all times. We have the right to restrict disclosure of certain records to you under federal and state law. By providing a confidential email address below, you agree that we may send to that email address a confidential user ID and password or a link to create a confidential user ID and password which will provide you access to the patient portal. You agree and understand that protection of this confidential login information is up to you and not our responsibility once we have provided you with the initial email. You further acknowledge that we will use this email address as our means of communicating to you regarding information sent to the patient portal. Communicating via the patient portal is not intended for medical treatment purposes. If you have a life-threatening emergency, please call 911 and seek medical attention immediately.
By signing below, I acknowledge that I have read and fully understand the patient portal terms listed above. I acknowledge that I am at least 19 years of age and that I am requesting access to the patient portal. I acknowledge that the patient portal is offered as a courtesy to our patients and I agree that you may terminate your access to the portal at any time for any reason, with or without notice.
I authorize you to send my medical records, through the patient portal, to the confidential email I provided.
TELECARE INFORMED CONSENT
Telecare is healthcare provided by any means other than a face-to-face visit. In telecare services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.
· I understand that telecare involves the communication of my medical/mental health information in an electronic or technology-assisted format.
· I understand that I may opt out of the telecare visit at any time. This will not change my ability to receive future care at this office.
· I understand that telecare services can only be provided to patients, including myself, who are residing in the state of at the time of this service.
· I understand that telecare billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.
· I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:
• It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.
• Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.
• Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.
· I agree that information exchanged during my telecare visit will be maintained by the doctors, other healthcare providers, and healthcare facilities involved in my care.
· I understand that medical information, including medical records, are governed by federal and state laws that apply to telecare. This includes my right to access my own medical records (and copies of medical records).
· I understand that Skype, FaceTime, or a similar service may not provide a secure HIPAA-compliant platform, but I willingly and knowingly wish to proceed.
· I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others.
· The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.
· I agree that I have verified to my healthcare provider my identity and current location in connection with the telecare services. I acknowledge that failure to comply with these procedures may terminate the telecare visit.
· I understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telecare and to confirm that he or she is my healthcare provider.
· I understand that electronic communication cannot be used for emergencies or time-sensitive matters.
· I understand and agree that a medical evaluation via telecare may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.
· I understand that electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.).
· I understand that my healthcare provider may choose to forward my information to an authorized third party. Therefore, I have informed the healthcare provider of any information I do not wish to be transmitted through electronic communications.
· By signing below, I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telecare visit.
· I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided.
· To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telecare visit.
· I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community.
I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature with the opportunity to have questions answered to my satisfaction.
If not signed by the patient: I certify that I have explained the nature of this agreement to the patient/patient’s legal representative. I have answered all questions fully, and I believe that the patient and/or their legal representative fully understands what I have explained.
I certify my understanding and agreement to all the information above and consent to be seen via telecare by a provider of AFC Urgent Care under the terms and conditions outlined above.