refund policy
GENERAL CONSENT TO TREAT:
I have the right, as a patient, to be informed about my condition and the recommended medical or diagnostic procedure to be used so that I may decide whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. I understand that this consent form is simply an effort to obtain my permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides Combat Medic Wellness (CMW) with my permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing below, I indicate that I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended; and I consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. I understand I have the right at any time to discontinue services. I have the right to discuss the treatment plan with my healthcare provider about the purpose, potential risks, and benefits of any test ordered for you. I understand that if I have any concerns regarding any test or treatment recommended by my healthcare provider, it is encouraged to ask questions.
I voluntarily request a healthcare provider or designees as deemed necessary, to perform reasonable and necessary medical examination, testing, and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive, or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. I understand that this authorization is valid for one calendar year, from the date listed on this form. I understand that if I refuse to sign, such refusal will result in the practice/clinic’s inability to provide healthcare to me today.
CONSENT AND PRIVACY POLICY
Consent for Care:
I authorize Combat Medic Wellness, and any employee working under the direction of Combat Medic Wellness to provide healthcare for me. This medical care may include services such as preventative services, diagnostic, therapeutic, maintenance, counseling, assessment of physical and/or mental status, recommendations for care, referral, prescriptions, and follow-up care.
Financial Policy:
I understand that my fee covers the time and expertise of the providers at Combat Medic Wellness. While every attempt will be made to treat my concerns, I understand that in some cases, referral is required. I understand that Combat Medic Wellness is an out-of-network provider, this allows them to spend more time with me without the limitations placed by an insurance plan, and the fee will be due in full at the time of the appointment. If I am unable to pay at the time of your visit, I understand that my visit will be rescheduled. Combat Medic Wellness accepts most major credit cards and can utilize an HSA or FSA account. Because they are an out-of-network provider, I realize my insurance may or may not cover the visit and the reimbursement may vary in coverage, and it is my responsibility as the patient to understand medical benefits and requirements. I understand that CMW recommends that the patient verify insurance benefits for any procedures, tests, or other services scheduled. I will be responsible for 100% of your total out-of-pocket responsibility amount prior to any procedures, visits, testing, or services.
Privacy Policy:
Combat Medic Wellness will not share my demographic or healthcare information with anyone except my insurance company, as noted above, or any other party unless another consent form giving this permission is signed. I understand that Combat Medic Wellness will maintain my healthcare information in a secure electronic health record.
Communication about MY Healthcare:
I agree that the provider and/or agent of the provider or the clinic office may contact me to schedule necessary follow-up visits recommended by the treating provider.
Use of Electronic Medical Health Record:
This practice/clinic uses an electronic health record that will update all of my demographics and consent with the information I provided. I understand that this information will also be updated for my convenience to all our affiliated locations that share an electronic health record in which you have a relationship. I authorize this practice/clinic to use their electronic health record to keep all of my health records at this time.
Use of ePrescribing via our Electronic Medical Health Record:
Our practice participates in ePrescribing via our electronic medical record (EMR) which has achieved Certification Commission for Health Information Technology (CCHIT) certification. Electronic prescriptions are submitted to the pharmacy designated by the patient.
Use of Telemedicine/Telehealth Services:
I authorize and agree that some services may involve the use of telemedicine or tele-health equipment and interaction with providers that are outside of my physical presence. I understand that I will be advised in advance of any such use of technology. I agree to notify the provider of my location honestly and to notify them of any changes before any tele-health visit. I am aware that my provider will also make every effort to ensure I am in the location I reported before my visit, and I understand that my visit will be canceled if I am not in the location I reported and/or a location in which the provider is licensed.
Consent for Photographing or Other Recording for Security and/or Health Care Operations:
I consent to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the practice/clinic’s health care operations purposes (e.g., quality improvement activities). I understand that the practice/clinic retains the ownership rights to the images and/or recordings. I will be allowed to request access to or have copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used outside the facility without written authorization from me or my legal representative unless otherwise permitted or required by law.
Consent to Email, Cellular Telephone or Text usage for Appointment Reminders/Healthcare Communications:
If at any time I provide an email address or cellular phone number at which I may be contracted, I consent to receive unsecured instructions and other healthcare communications at the email or text address I have provided to CMW or that the EBO Servicer has obtained, at any text number forwarded, or transferred from that number.
These instructions may include but are not limited to, post-procedure instructions, follow-up instructions, educational information, and prescription information. Other healthcare communications may include but are not limited to, communications to family or designated representatives regarding my treatment or condition or reminder messages regarding appointments for medical care. I understand that I may opt out of these communications at any time. The practice/clinic does not charge for this service, but standard text messaging rates or cellular phone minutes may apply as provided in your wireless plan.
CANCELLATION/NO-SHOW/RESCHEDULE/REFUND POLICY
Patients shall notify CMW by text (not voicemail) to 480-304-0249 -24 hours in advance that they must cancel/reschedule their online consult appointment.
Patients who fail to attend their scheduled online consult or are unprepared for their online appointment (FOR ANY REASON) will incur a $99.00 fee to rebook a second online consult.
If the patient declines to pay the $99 rebooking fee & instead chooses to receive a refund, the patient will be refunded all the money they have paid, MINUS $99 for the consult time they did not attend or were not prepared for.
Patients agree to incur this fee because they understand that if they miss their appointment or are not prepared for their appointment (FOR ANY REASON), CMW can not fill the doctor's consult time with someone from our waiting list. As a result, CMW incurs missed revenue because they were not provided adequate time to find a replacement patient for the missed consult time.
Prior to your online consult, patients will be texted (to the phone number they provided on the medical history form) the details of EXACTLY what must be done to be considered "prepared" for your online consult. Failing to follow the pre-set guidelines will result in the $99 fee being withheld from your refund.
By signing below, I agree to and understand Combat Medic Wellness's cancellation/no-show/reschedule/refund policy.
CONSENT FOR OFF-LABEL MEDICATION IF INDICATED
Many medications are FDA-approved for safe and effective treatment for a particular indication (medical problem). Sometimes, we prescribe medications for a different indication or a different population of patients. Examples of off-label treatment would be a testosterone product that is FDA-approved for men but is being prescribed for a woman in a different amount or a medication like semaglutide that is FDA-approved for obese persons or overweight diabetics with co-morbidities but not people of normal weight or overweight non-diabetics.
When a medication is prescribed off-label, it most likely will not be covered by your insurance, and we cannot provide prior authorization, but it is not illegal to prescribe off-label. This is done at the discretion of the provider. Often, medications are used off-label because there is no FDA-approved alternative treatment or the side effects of the approved medication are not tolerated by the patient. If you have any questions about your medication(s) being off-label, please feel free to ask our providers.
I have been informed that any medications that I have been/will be prescribed are considered off-label. I understand the FDA approved this medication for a different purpose and that this medication is not currently FDA-approved for this specific use.
Nevertheless, I am willing to accept the potential risks that my physician discussed with me and acknowledge there may be other, unknown risks and that long-term effects and risks are unknown.
By signing below, I understand the risks and benefits related to this medication and consent to the prescription.
Dispute Resolution.
Mediation and Arbitration Clause
Any controversy or claim arising out of or relating to this Agreement, the relationship resulting in or from this Agreement, or breach of any duties hereunder will be settled by Arbitration in accordance with the Arbitration Rules of the U. S. Arbitration & Mediation (“USA&M”) which may be found at www.usam.com. All hearings will be held in Phoenix, AA, before an Arbitrator who is a licensed attorney with at least 15 years of experience. A judgment upon the award rendered by the Arbitrator shall be entered in a Court with competent jurisdiction. The Federal Arbitration Act (Title 9 U.S. Code Section 1 et. seq.) shall govern all arbitration and confirmation proceedings.
As a condition precedent to the filing of an arbitration claim, the parties agree to first mediate any claims between them at USA&M. Any party refusing to mediate shall not prevent the other party or parties from pursuing their claims in arbitration. The parties will share the cost of mediation equally. Nothing herein will be construed to prevent any party’s use of injunction, and/or any other prejudgment, provisional action, or remedy. Any such action or remedy will not waive the moving party’s right to compel arbitration of any dispute.
The parties also agree to meet and negotiate in good faith to resolve any disputes that may arise between them.
THIS AGREEMENT CONTAINS AN ARBITRATION PROVISION, WHICH MAY BE ENFORCED BY THE PARTIES.
Name of Contact Person:
Combat Medic Wellness, Joseph Manchak, 480-304-0249
Please sign below indicating you have read and understand your Patient Rights.