Consent for Treatment
Authorization for Treatment: I voluntarily consent to the administration and cost of medical and surgical procedures, x-ray, and medication for myself and my dependents.
Assignment of Insurance Benefits: I authorize payment directly to this urgent care center for all benefits otherwise payable to me.
Guarantee of Payment: I understand that I am financially responsible and agree to pay all of the charges that are not paid or billed to insurance or any third-party payer. I understand that I must pay in full today for all services rendered unless my insurance is accepted. I also understand that if my insurance is accepted, I must pay all applicable insurance copays, coinsurances, and deductibles today. If you are unable to verify my insurance at time of service, I will pay in full for all services.
Release of Records: I authorize this urgent care center to release (verbal or in writing) confidential medical information To any person or entity including my insurance carrier, employer if treatment is related to employment purposes, or other health care operations which may be liable to me or my practitioners) for charges for this treatment and for quality management, utilization review, transfer, and follow-up purposes.
Receipt of Privacy Practices: I acknowledge that I have received and read the notice of privacy practices of this urgent care center.
I understand that a copy of this agreement may be used with the same effectiveness as the original.
HIPAA Compliance
Our notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or health care operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected health care information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you.
However, such a revocation will not be retroactive.
By signing this notice, I understand that:
Authorization for Treatment: I voluntarily consent to the administration and cost of medical and surgical procedures, x-ray, and medication for myself and my dependents.
Assignment of Insurance Benefits: I authorize payment directly to this urgent care center for all benefits otherwise payable to me.
Guarantee of Payment: I understand that I am financially responsible and agree to pay all of the charges that are not paid or billed to insurance or any third-party payer. I understand that I must pay in full today for all services rendered unless my insurance is accepted. I also understand that if my insurance is accepted, I must pay all applicable insurance copays, coinsurances, and deductibles today. If you are unable to verify my insurance at time of service, I will pay in full for all services.
Release of Records: I authorize this urgent care center to release (verbal or in writing) confidential medical information To any person or entity including my insurance carrier, employer if treatment is related to employment purposes, or other health care operations which may be liable to me or my practitioners) for charges for this treatment and for quality management, utilization review, transfer, and follow-up purposes.
Receipt of Privacy Practices: I acknowledge that I have received and read the notice of privacy practices of this urgent care center.
I understand that a copy of this agreement may be used with the same effectiveness as the original.
HIPAA Compliance
Our notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or health care operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected health care information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you.
However, such a revocation will not be retroactive.
By signing this notice, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipts of treatment upon execution of this consent.
Xpress Urgent Care
In-Person Walk-In Care in Flat Rock, Michigan
Minor Illness & Injury Care | Digital X-Rays | Physicals | Testing
In-Person Walk-In Care in Flat Rock, Michigan
Minor Illness & Injury Care | Digital X-Rays | Physicals | Testing