Medical Consent: I consent to any treatments or procedures which may be performed on an outpatient basis (including emergency treatment or services), which may include but are not limited to medications, injections, taking of medical photographs, laboratory procedures, and/or x-ray examinations provided to me under the general and special instructions of the physicians, staff, or other health care providers assisting my care.
Financial Agreement: I understand that all charges are due at the time of service. I agree to pay for all charges for healthcare services and professional services provided to me by physicians and other healthcare professionals. Acceptable forms of payment include Cash, Visa, MasterCard, Discover, and American Express. If I am a non-insured patient, I agree to pay for my visit in full at the time of service. If the medical provider is a participating provider with my insurance company, I understand that my co-pay, coinsurance, deductible, and/or any outstanding balances are due at the time of service. I understand that my insurance policy is a contract between myself and my insurance company, the medical provider is not involved. In order for the medical provider to file claims and accept payments from my insurance carrier, I understand that I must present current insurance information at each visit and that the medical provider will need to verify my health insurance coverage. In the event that the medical provider is unable to verify my insurance eligibility and benefits before my visit, I agree to pay for my visit in full at the time of service. A refund will be issued if my insurance pays for the visit. I also understand that I am financially responsible for any services not covered by my insurance company. When my spouse or a financial guarantor signs this agreement, the spouse or financial guarantor shall be jointly and individually liable with me. Should my account(s) be referred to an attorney or a collection agency for the collection, the undersigned shall pay the actual attorney's fees (including costs) and collections expenses incurred in addition to the other amounts due. Unpaid accounts referred to outside agencies for collection shall bear interest at the current rate per year from the date of referral.
Insurance Authorization and Release: I request the payment of authorized benefits, including Medicare, and any other government-sponsored program, private insurance, and any other health plans to be made to the medical provider for any services furnished by that provider. To the extent necessary to coordinate my health care or determine liability for payment and to obtain reimbursement for services rendered, I authorize the medical provider to disclose portions of or all of my records, including my medical records to any person or corporation which is or may be liable for all or any portion of the medical provider charges, including but not limited to insurance companies, health care service plans, governmental agencies, or worker's compensation carriers. I authorize the medical provider to act as my agent to help me obtain any required pre-certification as well as acting as my agent to help me obtain payment from my insurance companies. I authorize my insurance companies to give the medical provider any information required to fulfill this function. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the original.
Release of Medical Information: I hereby authorize the medical provider to release any information in my chart to any practitioner, doctor, hospital, or medical institution to which I may be referred to assist in my care. Additionally, I authorize the medical provider to provide a copy of my medical records to my Primary Care Physician (PCP) to allow for continuity of care.
Notice of Privacy Practices: By signing this form, you acknowledge receipt of the "Notice of Privacy Practices (HIPPA Compliance Patient Consent Form)" of the medical provider. Our "Notice of Privacy Practices" provides information about how we may use and disclose your protected health information. We encourage you to read it in full. Our "Notice of Privacy Practices" is subject to change.
Personal Valuables: The medical provider shall not be liable for the loss of or damage to any money, documents, jewelry, glasses, dentures, furs, or other articles of unusual value and shall not be liable for loss or damage to any personal property. The medical provider, a medical corporation, and the patient or the patient's representative, hereby enter into this agreement. The undersigned certifies that he/she has read and agree to the foregoing, and is the patient, the patient's representative, or is duly authorized by the patient as the patient's general agent to execute the above and accept its terms.
Arbitration: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of the date of my signature below stating that I want to withdraw from this agreement.
NOTICE: BY SIGNING THIS CONTRACT, YOU ACKNOWLEDGE AND CONSENT THAT YOUR ELECTRONIC SIGNATURE HOLDS THE SAME LEGAL VALIDITY AS YOUR HANDWRITTEN SIGNATURE, AND YOU AGREE TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE RESOLVED THROUGH NEUTRAL ARBITRATION, FOREGOING YOUR RIGHT TO A JURY OR COURT TRIAL. PLEASE REFER TO THE ARBITRATION ARTICLE OF THIS AGREEMENT FOR FURTHER DETAILS.
By checking this box, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure.
I am the parent/guardian of this patient