1. General Consent for Treatment. I voluntarily consent to and authorize such care and treatments, including but not limited to physical or mental examination, diagnostic tests, medical procedures and medications ("Treatments"), by employees and authorized agents of Union Medical Care, PLLC ("Clinic") as may be considered necessary or advisable in their professional judgment, and may include the drawing and testing for blood borne diseases. I further acknowledge that no guarantees have been made regarding the effect such treatments on any medical condition. 2. Right to Refuse Treatments. I understand that I have the right to make informed decisions regarding all care and treatments, and that I should ask my health care professional to further clarify or explain anything I do not understand. This right includes the right to refuse any treatments that I do not want. 3. I authorize the release of any medical information necessary to process this bill to my insurance company, and request payment of benefits it Union Medical Care, PLLC. 4. Acknowledgment of Receipt of Notice of Privacy Practices. I acknowledge that I have received the Health Notice of Privacy Practices and acknowledge that this notice is available for me to keep. 5. I acknowledge that I have read, understand and agree to the terms and conditions of this form and that I am authorized as the patient or the Patient's Representative to acknowledge this document and be bound by its terms. I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the facility and the facilities listed at the beginning of this notice, and how I may obtain access to and control this information. I also acknowledge and understand that I may request copies of separate notices explaining special privacy protections that apply to HIV-related information, sexually transmitted diseases, alcohol and substance abuse treatment information, mental health information, and genetic information. 6. I have been advised of my rights to obtain access to and control my protected health information. I also understand that in providing treatment, submitting billing and conducting healthcare operations. Kamin Health Urgent Care may need to disclose my protected health information to members of my family or certain close personal friends. By providing the requested information below, I further authorize the disclosure of my protected health information as follows: If I am unavailable, I expressly permit Kamin Health Urgent Care to disclose my protected health information for the purposes of appointment/test/procedure reminders and follow-up. I expressly permit Kamin Health Urgent Care to disclose my protected health information for the purposes of conveying test results for this event by leaving such information in the form of a message on my phone or email that I have provided today.