Treatment and Privacy Consent: I give my consent for medical evaluation and treatment by health care personnel within Epic Urgent and Family Care (EUFC); this may include, but not be limited to: examinations, xrays, blood draws, laboratory tests, minor procedures, administration of medications and immunizations, and completion of medically appropriate testing for communicable and other diseases. I acknowledge that no guarantees have been made to me as to the diagnosis or result of exam or treatment.
I authorize EUFC to use and disclose my information for the purposes of treatment, payment, and healthcare operations. A copy of EUFC’s HIPAA Notice of Privacy Practices is available for my review upon request.
Communication Consent: In order to enhance patient care and experience, EUFC may contact you after your visit in order to request feedback on your experience bt phone call, SMS text message, e-mail, voicemail, or mobile application, some of which may be via automated means. By signing below, you understand and agree to be contacted in this manner with communications related tp this visit and any future visits. You may opt-out of receiving text messages by notifying us in writing or responding via text messages.
You are agreeying to this paragraph if chose self-pay: I choose to pay for today’s visit because: I have no insurance coverage; or I am opting out of using my insurance; or I believe my service today is not covered by my insurance plan. I understand that Epic Urgent & Family care provides discounted services for qualifying charges when a patient opts for self pay. Payment in full is due at the time of service. I understand that by choosing this option, today’s services will not be submitted to my insurance even if it is later determined that the service is covered. No billing codes, HCFA forms, or detailed receipts will be available for reimbursement from an insurance company.
You are agreeying to below if chose Insurance: I authorize and request my insurance company or third party payor to pay directly to EUFC for services rendered to me. EUFC representatives do their best to verify eligibility but insurance plans vary. I agree that I will be responsible for payment of the complete charges for all services not covered by my insurance carrier/third party payor. I agree that it is ultimately my responsibility to understand my coverage and limitations as defined by my insurance. Once billed to insurance, charges cannot be converted back to self pay prices. Copay and/or partial deductible will be due at the time of the visit.
If I do not pay the entire new balance within 25 days of the monthly billing date, I realize that EUFC may not be able to provide additional services except emergency care. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.