Have you or someone you have been in close contact with, traveled recently, been in contact with a confirmed Coronavirus (COVID-19) patient?
Do you have a fever, cough, or shortness of breath?
Would you like to schedule a telemedicine visit? If so, please read and acknowledge by checking the box giving consent.
Consent to treatment: I hereby authorize Elgin Urgent Care, my physician, a physician designated by him/her or with whomever he/she may designate as his/her assistant to render medical treatment, which they may deem necessary during a virtual visit. Any medications prescribed will be sent electronically to the pharmacy of my choice.
Assignment of insurance benefits and release of information: (1) I hereby authorize direct payment to KershawHealth, and to attending physicians, all benefits otherwise payable to me for this virtual visit by insurance companies or other agencies, for which I am responsible; and third ay excess payment after all accounts at KershawHealth have been paid in full will be refunded to me in compliance with the refund schedule established by KershaeHealth; (2) If an allowance is made on this account for the estimated insurance payments and the insurance company or companies does not take payments within 60 days of the virtual visit or pays an amount less than the amount allowed, I will make immediate payment of the balance due on this account; (3) I will pay an advance fee for each insurance claim filed by the hospital where complete insurance information is not furnished to the hospital prior to the patient’s discharge. I understand that I am financially responsible to the hospital for any charges not covered by this assignment.
Authorization for release of medical information/discharge placement: I hereby authorize KershawHeath to furnish any medical information requested by insurance companies with whom I have coverage or any public agency that may be assisting in payment for my care. I understand that in the process of locating a suitable placement, some facilities may request to review by medical record and to interview or assess the patient physically. I hereby authorize KershawHealth to inform facility representatives of confidentiality requirements and to obtain appropriate signatures for confidentiality statements.
Authorization to disclose information: I authorize KershawHealth, and all attending providers to release to the Social Security Administration, or its intermediaries or carriers, any information about me needed for this Medicare claim, including medical information relation to my treatment. Only information needed for processing my claim for Medicare benefits may be released.
I also authorize the release of medical and related information about my treatment to the Peer Review Organization responsible for reviewing the medical care furnished me by your institution.
I understand that health care services paid for under Medicare, and industrial programs may be subject to review by the Peer Review Organization.
I reserve the right to withdraw this authorization at any time.
I understand that my company’s hospital plan includes medical review and I hereby authorize the release of my hospital records for confidential review by the Peer Review Organization.
Consent for Contact: You agree that KershawHeath, including our business associates, may contact you by telephone at any telephone number you provide by you or associate with your record, including cell phone numbers, which could result in charges to you. Methods of contact may include using pre-recorded/artificial voice messages, and/or use of an automated dialing service as applicable.
By checking the assigned box, I certify that I have read (or have had read to me) and fully understand the above.
