Consent Form

Consent to Treat

I hereby authorize and consent to the performance of physical examination and treatment by a physician, physician assistant or nurse practitioner from Ennoble Care. I understand that this consent is given in advance. This may include ordering or performing blood draws, urinalysis, ultrasounds, x-rays, wound care, removal of sutures/staples and cerumen removal. If I am existing patient of my Provider, I hereby affirm that the content of this consent applies to my initial start of care with my Provider and any of Ennoble's other Providers.

I acknowledge that my Provider is a primary and palliative care Provider, and thus has the right to safely discharge me if the Provider-patient relationship is no longer feasible, including but not limited to situations of assault, threats, danger to the Provider, fraudulent use of controlled substances, and existing legal action. Upon request, my Provider will send Ennoble Care's written policy on ending a patient-Provider relationship, which further describes the reasons for discharge as well as the procedure.

Consent to Digital Medical Imaging

I acknowledge and consent to digital medical imaging (photography or video recording) to be made of me. I understand that any medical imaging is considered part of my medical record and will only be shared for the purposes of treatment or health care operations.

Consent to Release of Medical Records

I understand and acknowledge if my medical records are to be released to parties who are not my Health Care Provider or supplier, I will have to fill out a medical release form.

I acknowledge that Ennoble and my Provider may use and disclose medical information about me to provide, coordinate, or manage my medical treatment or any related services. This includes the coordination or management of my health care with a third party. For example, Ennoble or my Provider could disclose my medical information to a home health agency, physician, or hospital that also provides care to me.

Authorization to leave voice or text messages

I hereby authorize Ennoble Care and my Provider to text or call telephone numbers that I have provided. These text messages or phone calls will include detailed information about my next appointment (Provider name, date/time, and callback number), the availability of my test or exam results, account payments, balances, or cost estimates, and limited health information to the extent permitted by HIPAA.

I understand that I may revoke this authorization at any time, but I must do so in writing. Information disclosed pursuant to this authorization could be re-disclosed by the recipient. Such re-disclosure is in some cases not protected by state law and may no longer be protected by HIPAA.

Notice of Privacy Practices Acknowledgement

I acknowledge that I have been offered a copy of Ennoble Care Notice of Privacy Practices (NPP). I understand that the NPP provides information about how protected health information about me may be used and disclosed in providing care to me and receiving payment for that care. I understand that the terms of the notice may change as allowed by law.

Link to view NPP: Ennoble Care Notice of Privacy Practices Acknowledgement

Health Insurance and Financial Responsibility Acknowledgement

I request that payment of authorized Medicare/Insurance carrier benefits be made on my behalf to Ennoble Care, for any services furnished to me by that physician or supplier. I authorize any holder of medical information about me to release to the Centers of Medicare/Medicaid services and its agent and/or other Insurance Carriers for which I have Coverage, any information needed to determine these benefits payable for related services.

I understand and agree that charges for medical, non-medical and related professional services performed or supervised by a physician, nurse practitioner, or other medical Provider are my responsibility. I understand that my actual charges may be different from charge estimates given to me. I also understand that an insurance company may not pay the full amount of my charges, and I may be responsible (as a patient, spouse, or the parent of a minor child) for the amount not paid (e.g., for co-insurances, co-pays, and deductibles). If I do not have health insurance or have not provided current or accurate insurance information, I am responsible for payment of all charges. If I have overpaid any of my accounts, I agree that the overpayment may be applied to pay any outstanding charges on any of my other accounts with Ennoble.

Visit Cancellation

I hereby acknowledge that my Provider travels to my home to see me, and that my Provider's office will call to confirm my approximate appointment time before my visit. If I acknowledge the appointment time and confirm the visit, then I am responsible for being at the specified location during the time of the visit. If I am not there when the Provider arrives to the confirmed visit or if I cancel same day, I may be charged a $50 cancellation fee. Note that this fee does not apply for exigent circumstances (e.g., an emergent hospitalization).

Patient Portal

I understand that Ennoble Care has a patient portal, which can be found here: Ennoble Care Patient Portal. The patient portal includes information from my medical record, including appointment notes, lab results, and open invoices for patient responsibility.

To gain access to the patient portal, I understand that I will have to share a preferred email address with Ennoble Care (to be included in the my medical record) and then create an account after authenticating my identity.

Telehealth Informed Consent

Telehealth (also called telemedicine) is a way to visit with your healthcare Provider without being in person. The visits are held by computer, tablet, or telephone. I acknowledge and give permission for my Provider or Ennoble Care's team to communicate with me via telehealth. I understand that telehealth involves sharing my health information electronically, and telehealth visits carry some level of risk, including technical problems and the limitations of virtual care. I will tell my healthcare Provider if there is any information that I do not want to talk about in a telehealth visit.

Remote Patient Monitoring

I acknowledge that Ennoble Care and my Provider do and bill for Remote Physiologic Monitoring (RPM) services, which is the monitoring of patient health data such as blood pressure, weight, glucose, or other health information through interactive communication with the patient or caregiver during a calendar month. RPM services include: (1) app or email mechanism that enables you to keep your care team updated and informed about your vital health data, along with any symptoms you may be experiencing, (2) systematic assessment of your healthcare needs, and (3) care coordination based on patient-transmitted health data. I hereby give consent for those services, will discuss those services with my Provider and my Provider’s staff members, and understand that I have the right to revoke my consent for RPM at any time.

Care Management

I have been informed that my Provider bills Chronic Care Management (CCM) codes for our time-based non-face-to-face time. I have been informed that my Provider only bills if we meet criteria and document certain time-based tasks. I am also aware that a care plan is available upon request and can be provided to me and my other clinicians. Only one Medicare Provider may bill this code per month. I acknowledge that cost sharing may apply. I acknowledge CCM participation, have or will review CCM services with my Provider during a visit, and know that I can stop participation at any time, effective at the end of any given month.

I have been informed that my Provider also provides Behavioral Health Integration (BHI) services within our practice. For those patients that we include in this service line, we utilize psychiatric consultative services and have behavioral health managers on staff for use when clinically appropriate. I acknowledge that cost sharing may apply. I acknowledge participation in BHI.