I hereby voluntarily consent to outpatient care from the Primary Care Clinic at Partners Family Medicine Practice & Recovery Center encompassing routine diagnostic procedures, examination, and medical treatment including (but not limited to) routine laboratory work and administration of medications as prescribed by the Providers. I further consent to the performance of those diagnostic procedures, examinations, and rendering of medical treatment by the Primary Care Clinic at Partners Family Medicine Practice & Recovery Center's medical providers and staff, as is necessary in the medical staff's judgment. I understand that during treatment, health care workers may be exposed to the patient's blood and/or body fluids increasing their risk of contracting Hepatitis B, Hepatitis C, and/or HIV. In the event an exposure occurs, I understand the need for testing for these diseases and I agree to such testing of myself to promote the health and welfare of the health care worker. I understand that this consent will be valid and remain in effect if I attend the clinic. I am aware that my medication list and controlled medication list from the PMP will be shared with the Lab Director for specimen result analysis when indicated.
I hereby give authorization to utilize Telehealth services via HIPPA secured communication devices at Partners Family Medicine Practice & Recovery Center. I authorize my communications via online, audio, visual, or telephonic technology. I understand that I will be asked to Identify myself via a two-factor identification method which could be name, date of birth, last 4 of social security number, address, zip code, email, or telephone number and/or security questions. If at any time I make the decline to utilize Telehealth communication for my appointments or treatment plan services, I agree to provide this decline of service via writing.
I hereby authorize the Primary Care Clinic at Partners Family Medicine Practice & Recovery Center to release any information acquired during my examination and treatment to any authorized agent for the purposes of healthcare, treatment, and payment. I authorize the release of medical information to my insurers as necessary for determination and payment of benefits; to healthcare providers involved in my care; to utilization review and professional standards review organizations, companies, and community resources that assist me with my healthcare needs.
I have received the Partners Family Medicine Practice & Recovery Center Notice of Privacy Practices and Patient Rights.
I hereby authorize the Primary Care Clinic at Partners Family Medicine Practice & Recovery Center to access historical prescription drug information.
Partners Family Medicine Practice & Recovery Center
I understand that the Primary Care Clinic shall not be liable for loss or damages of any personal property.
The Primary Care Clinic endorses, supports, and participates in electronic Health Information Exchange (HIE) to improve the quality of your health and healthcare experience. HIE provides us with a way to share securely and efficiently patients' clinical information electronically with other physicians and health care providers that participate in the HIE network. Using HIE helps your health care providers to more effectively share information and provide you with better care. The HIE also enables emergency medical personnel and other providers who participate in the HIE program and who are treating you, to have immediate access to your medical data that may be critical for your care. Making your health information available to your health care providers through the HIE can also help reduce your costs by eliminating unnecessary duplication of tests and procedures. However, you may choose to opt-out of participation in the HIE, or cancel an opt-out choice, at any time by completing the appropriate form which will be provided upon your request. Partners Family Medicine Practice & Recovery Center endorses, supports and participates in the Immunization and Information System.
I acknowledge that my health care information will be shared with the Regional Data Base for Immunization and Information System. You may choose to opt-out of participation in the CIIS system or cancel an opt-out choice. This notification must be in writing and may be presented at any time.
I authorize the Primary Care Clinic at Partners Family Medicine Practice & Recovery Center to file a claim with my insurance carrier for services rendered. I authorize payment of medical benefits by any insurance carrier to either the Clinic or myself. I understand that insurance is a contract between myself and my insurance carrier. The Primary Care Clinic is not a party of this contract. We will bill your insurance carrier as a courtesy to you. In order to properly bill your insurance carrier we require that you disclose all insurance information including primary and secondary insurance cards, as well as, any change of insurance information within 60 days of service. Failure to provide complete insurance information may result in patient responsibility for the entire bill. It is the insurance company that makes the final determination of your eligibility and benefits. It is your responsibility to determine if your insurance company is contracted with us. If your insurance carrier is not contracted with us, you are responsible to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If your insurance carrier pays you directly, you are responsible for payment and agree to forward the payment to us immediately. All copayments, coinsurances, and deductibles may apply. Copayments are the patient's responsibility at the time services are rendered. If you are uninsured, please note that your account is your responsibility. No patient will be denied emergency treatment due to his/her inability to pay. Discounts for essential services are offered dependent on income and household size as compared to the current federal poverty guidelines. Please inquire for more details. The parent or legal guardian of a minor patient (under 18 years of age) is responsible for payment on the minor's account. Regardless of any personal arrangements that a patient might have outside of our office, if you are over 18 years of age or older and receiving treatment, you are ultimately responsible for payment of the service. Our office will not bill any other personal party. I understand that hospital services (i.e. laboratory tests and diagnostic images such as X-ray, CT, US, and MRI) are billed separately by the hospital and therefore not included in our charges. Clinic discounts do not apply to hospital bills.
The patient will need to contact the hospital regarding charges and payments.
- Notice of Privacy Practices: I have already received this information
- HIPAA Consent: I have already received this information
- Advanced Directives: I have already received this information
I understand that I may revoke this consent in writing; except to the extent that the organization has already taken action in reliance thereof. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me.
My signature below indicates that I understand and accept the content of this form.