Medicap Pharmacy and Interim HealthCare consistently strive to provide quality services in accordance with the highest ethical standards. We will not discriminate on the basis of race, color, sex, age, religion, national origin, sexual orientation, or disability.
I hereby acknowledge and consent that Medicap Pharmacy/ Interim HealthCare will deliver the following service(s) to the individual below - One Time Assessment for the purpose of: COVID-19 Testing.
I understand that for health care concerns I may have, I should contact my usual health care provider or physician.
I understand appropriately qualified health care personnel will provide these service(s). At any time while Medicap Pharmacy/Interim HealthCare employees/contractors are on assignment, and in the event of a medical emergency, I authorize Medicap Pharmacy/Interim HealthCare or its employees/ contractors to provide or obtain such medical treatment as they deem advisable under the circumstances, and I agree to assume sole responsibility for all charges for such treatment.
I hereby authorize Medicap Pharmacy/Interim HealthCare to release copies of my reports or such portions or summaries thereof as may be relevant, to other health care providers, facilities, or third-party payors for the purpose of my service, to obtain payment, and for health care operations.
I acknowledge that I have received a copy of the Medicap/Interim HealthCare Notice of Privacy Practices. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by Medicap Pharmacy/Interim HealthCare and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.