TREATMENT, PAYMENT AND PRIVACY AUTHORIZATION

I, as the patient seeking care, agree to the following consents, conditions, and authorizations proposed by Physicians Immediate Care (hereafter “Physicians”).

Can we treat the patient today?

I consent to the care and treatment by the physician providers, non-physician providers, and assistants of Physicians Immediate Care. I acknowledge that no guarantee has been made as to the effect or outcome of such treatment.

Can we release information to collect payment?

I authorize Physicians to release medical or other information about the patient that may be necessary for the provision and review of services, the receipt of benefits, or the completion of invoices or insurance claims to be presented to the financially responsible party, including, but not limited to, workers’ compensation carriers or employer, subject to applicable federal and state law limitations. Such information may include current medical records. Physicians may release such information to third-party payors, including, without limitation, any parties responsible for payment of charges for any services rendered during the patient’s treatment.

Do you have a copy of our privacy practices?

By providing your email address and/or cellular telephone number, you consent to occasionally receiving emails and text messages (as applicable) featuring news, updates, billing/appointment reminders, health care related matters, surveys, and commercial content from Physicians Immediate Care LLC. To the extent my records are considered protected health information or medical records pursuant to state and federal law, I understand that Physicians will protect the privacy of my health information and will not use or disclose it except as permitted by state and federal law, as described in the Notice of Privacy Practices that has been made available to me. I understand that the Notice of Privacy Practices may change and impact the patient’s rights related to protected health information and Physicians’ obligations.

Employer HIPAA Release Notice

Disclose Protected Health Information to Prospective Employer, Employer or Service Agent of the Employer.

Please note: If you are presenting for DOT drug and/or alcohol testing, you are not required to sign a consent, release, waiver of liability or indemnification agreement with respect to any part of the drug or alcohol testing process covered by Subpart 40.355 of the Title 49, Transportation, Federal Drug and Alcohol Testing Rules.