PATIENT CONSENT FORM

Health Check and Treatment Consent Integrated Care / Collaborative Care / Care Management

Purpose of this Consent Form: As a tax-exempt, community-based medical practice, we are committed to providing the best possible healthcare services to our patients at Health Empowerment Network of Maryland, Inc. We want to ensure that you are fully informed about the monthly health check, care coordination services, and treatment you will receive and obtain your consent to allow us to provide your care. This form is also offered to parents, guardians, or caregivers of patients who may not be capable of making informed choices about their healthcare.

General Consent and Conditions of Treatment: By signing this consent form, you agree to the treatment that our Integrated Healthcare team will provide, as well as their social care coordinators, medical assistants, and other staff members. You will have a medical record prepared and maintained about you, and you are entitled to obtain a copy of your medical record by signing a Medical Records Authorization Form provided for that purpose. In emergencies, a member of our Integrated Healthcare team may be necessary or advisable to perform services and/or procedures that may not be fully discussed with you or your caregiver in advance. However, we will always prioritize your health and safety.

Student Participation: We educate the next generation of healthcare professionals and students. The types of students may include premed students, medical students, medical residents, nursing students, nurse practitioner students, and other healthcare education programs. While we encourage participation in this valuable process, you can decline the participation of any student or trainee in your care at any time.

Communication With Health Care Providers: We prioritize safeguarding your health information. Our practice is to convey test results to patients by phone, mail (to the address provided by the patient or caregiver), or in person to ensure your privacy and security. Policies do not permit discussions about your health information or transmission of your test results via email, as email is generally not a secure method of communication. You always have the option to call or make an appointment to discuss your test results or health issues with a provider or other member of the Integrated Healthcare team.

Authorization to Coordinate Care with Other Healthcare Providers: We may have to coordinate with various healthcare providers and ancillary support providers to manage your health. By signing this form, you consent to allow any member of our Integrated Healthcare Team to share medical information as needed to coordinate and manage your healthcare services.

Billing and Collection: We seek to provide affordable healthcare services to all our patients. By signing this form, you allow us to share your information with your insurance company to seek reimbursement for rendered services and any third parties that may be involved in billing or collection for services provided by our Integrated Healthcare team. We will verify insurance coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for paying your bill if your insurance does not cover the required services.

Authentication: We take the security of your medical information seriously. Thus, we require patients to provide identification in connection with visits or any telephone calls in which personal information may be requested. This helps us ensure we are not divulging personal information or treating an unauthorized person. If you cannot provide the necessary identification, we may not be able to treat you or provide the information you are seeking from your medical record until you satisfy the Practice authentication requirements. Such documents will include your valid state-issued driver's license and/or a picture I.D. from your employer.

Notice of Privacy Practices: By signing this form, you acknowledge receipt of our Notice of Privacy Practices, which outlines how we protect your personal information and maintain your privacy.

Validity of Consent: Your consent to this form shall be valid as long as you receive services from our Integrated Healthcare Team. You can withdraw your consent at any time by providing written notice. The withdrawal of consent will only apply after it is received and not to any information you previously provided. We hope this consent form provides all the information you need to make an informed decision about your healthcare. By signing this form, you acknowledge that you have read, understood, and accepted the terms of this Consent Form.

On behalf of the Board of Directors for Health Empowerment Network of Maryland, Inc., I would like to welcome you to our organization and its services. We look forward to providing you with the best possible care.

By signing below, I acknowledge that I have read, understood, and agree to the Consent Form Guidelines.