Patient Acknowledgement and Consent Form
Native Wellspa & Weight loss Centre is operated by Native Healhcare Center. Thank you for choosing Native Healthcare Center as your healthcare provider. The medical services you seek imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full for the services you receive. To assist in understanding financial responsibility, we ask that you read and sign this form. Feel free to ask if you have any questions regarding your financial responsibility. On behalf of myself, my minor child, or the patient named below, I hereby acknowledge and consent to the following statements made in this form:
Consent to Medical Treatment and Health Care Services
| I am requesting that health care services be provided to me (or my minor child or the patient named below) at Native Healthcare Center. I voluntarily consent to all medical treatment and healthcare-related services that the health providers at Native Healthcare Center consider to be necessary for me (or the patient named below These services may include weight loss programs, consultations, diagnostic, therapeutic, imaging, minor procedures, immunization, and laboratory services, including COVID 19, Influenza, and/or HIV testing. I am aware that the practice of medicine is not an exact science; no guarantees have been made to me about the results of treatments or examinations. I also understand that Native Healthcare Center may provide certain services through remote telehealth technology. Such telehealth services involve a health provider who is at a site remote from my location at the time of the service, and, as such, telehealth often involves the transmission of video, audio, images, and other types of data. The remote health provider will determine whether the condition being diagnosed or treated is appropriate for telehealth. Further, I understand that I may have to travel to see a health provider in person for certain diagnosis and treatment matters.
Individual Financial Responsibility
WE ARE A CASH-BASED BUSINESS. If you choose to use health insurance for services such as labs, etc., it is your own responsibility to make a direct request through your healthcare insurance provider for reimbursement. I am ultimately responsible for all payment obligations arising out of my treatment or care and guarantee payment for these services. I am responsible for deductibles, co-payments, CO insurance amounts, or any other patient responsibility indicated by my insurance carrier or our financial policies that are not otherwise covered by supplemental insurance. If my insurance carrier or health at one, not I will be for the plan determines services are possible completely payable, charge services provided. If I am uninsured, I agree to pay for the medical services rendered to me at the time of service.
Assignment of Benefits/Third-Party Payers
I hereby authorize and direct payment of my medical benefits to Native Healthcare Center on my behalf for any services furnished to me by the providers. In consideration of all health care services rendered or to be rendered to me (or the below-named patient), I hereby assign to Native Healthcare Center all rights, titles, and interests in and to any third-party benefits due from any and all insurance policies and/or responsible third-party payers of an amount not exceeding Native Healthcare Center's regular and payments applicable customary charges party containing customary charges request for review or appeal by Native Healthcare Center to challenge a determination of benefits made by a third-party payer. Except as law requires, I assume responsibility for determining in advance whether the services provided are covered by insurance or another third-party payer.
Uses and Disclosures of Health Information
I have received the Native Healthcare Center Notice of Privacy Practices. This Notice of Privacy Practices describes how Native Healthcare Center may use and disclose confidential information that discloses health identifies me(or the patient). I hereby authorize Native Healthcare Center to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization, or referral to other medical providers. I consent to receive, on the telephone number(s) that are provided to Native Urban Healthcare on this form or updated at a later time, text messages and/or telephone calls from Native Healthcare Center LLC and its affiliates, along with any billing services, collection agencies, agents, or other third parties who may act on their behalf. Such text messages and/or telephone calls may be related to any purpose. I understand this consent to communications is not required to receive services from Native Healthcare Center or any of the other authorized callers and that data usage and other charges may apply. I may revoke this consent to these communications at any time.