Consent for Care, Services, Financial Responsibility, and Office Policies

At Rahma Health, we are committed to providing comprehensive, high-quality care while ensuring transparency in our policies. Please review this consent and policy agreement carefully. Your signature confirms your acknowledgment and agreement to the terms outlined below.

General Consent for Medical Treatment

I consent to receive medical care, diagnostic procedures, and treatments provided by Rahma Health's healthcare professionals. I understand these services aim to diagnose, treat, or manage my health condition(s), and I will be informed about my care plan, including potential risks and benefits.

Advanced Primary Care Management (APCM)

I consent to participate in Rahma Health’s APCM program, which improves care through coordination, prevention, and chronic disease management. I understand:

• Only one provider may deliver and be reimbursed for APCM services each month.
• I can opt out of APCM services at any time
• Cost-sharing (copays, coinsurance, or deductibles) may apply per my insurance plan.

Patient Financial Policy

I understand and agree to the following:

• I am responsible for reviewing my insurance coverage regarding copayments, coinsurances, and deductibles, which are due at the time of service.
• If Rahma Health participates with my insurance, the practice will bill my insurance company; however, I am responsible for any amounts not covered by my insurance, including denied claims.
• If Rahma Health does not participate with my insurance or I do not have insurance, I will pay the full cost of services at the time of the visit.
• Payment methods include cash, check, or credit/debit card. A $25 fee will be charged for any returned checks.
• Past due accounts may incur collection, attorney, and applicable finance charges, which I am responsible for.

Cancellation Policy

• I agree to provide at least 48 hours' notice if I need to cancel or reschedule an appointment. Failure to do so or not showing up for my appointment may result in a $50 charge.
• Missing two appointments in a year without notice may lead to discharge from the practice.
• If I am more than 15 minutes late for an appointment, it will be rescheduled.

Controlled Substances Policy

• Patients prescribed controlled substances (e.g., opioids, benzodiazepines) must be seen monthly for refills unless otherwise directed.
• Patients requiring continued refills of controlled medications for chronic medical conditions may be referred to a specialist for ongoing care, including refills.

Paperwork Policy

Paperwork requests (e.g., forms for work, insurance, or disability) require up to seven days for completion. Fees start at $25 per form, depending on the complexity, and payment is due when the paperwork is dropped off. Insurance does not cover these charges.

Text/Email Consent

• The primary method of communication with Rahma Health is through the patient portal or telephone.
• Occasionally, I may receive email or SMS text messages from Rahma Health regarding my medical care, including test results, prescriptions, appointments, and billing.
• I understand that these communications are not confidential and may be intercepted by third parties. I acknowledge that text messages are used sparingly and not as the primary communication method.

AI Transcription Technology

• Rahma Health utilizes HIPAA-compliant generative AI transcription technology to create medical notes.
• This technology operates as a virtual scribe, and all transcriptions are reviewed by the attending physician before being added to my medical chart.
• I may verbally opt out of this service during a visit if I choose.

Authorization for Insurance Payment and Release of Information

• I authorize my insurance company to pay Rahma Health directly for services rendered.
• I agree to be responsible for any amounts not covered by my insurance.
• I authorize the release of necessary information for the payment of charges incurred.

Acknowledgment and Consent

By signing below, I confirm that I have read, understand, and agree to the terms, including financial responsibility.

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow up among the multiple health care providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal health care operations such as quality assessments and physician certification.

I have received, read and understand your HIPAA Notice of Privacy Practice containing a more complete description of uses and disclosures of my health information. I understand this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree that you are bound to abide by such restrictions.