• Consent of Treatment

  • CONSENT: I consent to medical services discussed and ordered by a physician and given by HorizonView Health. HorizonView Health may share health information about me, my guardian(s) or parent(s) to physicians and providers who treat me.

    FINANCIAL AGREEMENT: I, the patient or guarantor, certify that the information provided is true to the best of my knowledge. I accept responsibility for the medical charges incurred by the patient and agree to pay all bills at the time of service unless arrangements are made. I authorize HorizonView Health, to release any information to process insurance claims. I also authorize my insurance claim to be paid directly to HorizonView Health.

    RELEASE OF INFORMATION: I permit HorizonView Health to release information needed for eligibility and benefits, and to process claims for payments. I agree that all insurance payments be paid directly to HorizonView Health for services rendered.

    By my signature below, I agree to the Consent of Treatment & have received the Notice of Privacy Practices of HorizonView Health.

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  • Notice of Privacy Practices Acknowledgement

  • This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and Privacy Practices with respect to PHI. We are required to abide by the terms of the Notice of Privacy Practices. We reserve the right to change the terms of the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices upon request.

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  • Telemed Consent Form

  • A Telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovisual equipment (Zoom). This consent is valid for all follow-up Telehealth services with HorizonView Health.

    I understand that:

    • I can decline the Telehealth service at any time without affecting my right to future care or treatment.
    • If I decline the Telehealth services, the alternative option would be in-person services.
    • The same confidentiality protections that apply to my other medical care also apply to the Telehealth services.
    • I will have access to all medical information resulting from the Telehealth service as provided by law.
    • The information from the Telehealth service (images that can be identified as mine or other medical information from the Telehealth service) cannot be released to researchers or anyone else without my additional written consent.
    • I understand that my insurance will be billed for the telehealth services, and that I will be billed for what my insurance does not cover. By signing this consent, I am giving permission to release information to my insurance company or third-party payor for billing purposes.
    • I have read this document carefully, and my questions have been answered to my satisfaction. I understand this consent is valiid for all telehealth follow-ups at HorizonView Health.
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