Consent for Medical Care

I voluntarily give my consent to Medcare Group and physicians and other providers caring for me at Medcare Group to review my medical records and provide such diagnostic procedures and medical treatment as deemed necessary. I understand that the practice of medicine is not an exact science and that no guarantees are made concerning the results of medical treatment that will be provided to me.

RELEASE OF INFORMATION: Thereby authorize and consent to the release of all personal health information (including but not limited to my home phone, cell phone, work phone, address and email address, test results and their interpretation, treatment plans, account billing and collection, payment posting and/or processing), to any and all clinical providers responsible for my care and to all other persons requiring information for billing or healthcare operations and related functions. I authorize the Medcare Group and all clinical providers who have provided care or interpretation, along with any billing service, collection agency, or attorney who may work on their behalf, to contact me on my cell phone and/or home phone using pre-recorded messages, artificial voice messages, automatic telephone dialing services or other computer assisted technology, or by electronic mail, text messaging or by any other form of electronic communication.

ASSIGNMENT OF BENEFITS: In consideration of services to be rendered by Medcare Group and independent providers, I assign all of my benefits from any insurance or other third-party payer including Medicare and Medicaid to Medcare Group and/or the independent provider rendering the services.

RESPONSIBILITY FOR PAYMENT: I understand that I am responsible for payment of all bills for any services provided by Medcare Group or any independent clinical providers.

I acknowledge that I received the Notice of Privacy Practices of Medcare Group and its Medical Staff which sets forth the ways in which my personal health information may be used or disclosed and outlines my rights with respect to such information.

Patient Name *

First Name Last Name

Patient or Responsible Party Signature: *

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Date *

Date

Relationship of Responsible Party to Patient

Witness Signature *

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