GENERAL CONSENT TO CARE:
l, the undersigned, for myself or a minor child or another person for whom I have authority to sign, having registered at Jackson~Hinds Comprehensive Health Center{JHCHC) for the purpose of obtaining health services, do hereby voluntarily consent to such diagnosis and treatment service, as ordered by a provider, dentist or other qualified health care provider of JHCHC. This consent Includes my consent for all medical services rendered under the general or specific instructions of a provider; including treatment by a m!d~level provider (Nurse Practitioner or Physician Assistant), and other health care providers or the designees under the direction of a physician, as deemed reasonable and necessary.
I recognize that I have the right to refuse any specific diagnostic or treatment service without jeopardizing my right to receive services at the heath center. I also recognize that I will be asked to sign a specific consent, as needed, for surgical and other special procedures including general and/or extensive local anesthesia.
I recognize that, according to the laws of the State of Mississippi, parental consent is not required in the case of a minor seeking treatment of a sexually transmitted infection or a female, regardless of age or marital status, seeking diagnostic or treatment services in connection with pregnancy or childbirth.
l agree and acknowledge that JHCHC is not liable for the actions or omissions of, or the instructions given by the physician, dentist or other qualified health care provider of JHCHC. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatments or examinations at JHCHC facilities. Further, I authorize the health center to furnish requested patient information to requisite legal, health, social and government entities, as needed.
AFTER HOUR ASSISTANCE
For after hour assistance, please call (601) 362-5321. An On-Call Representative will be available to assist you.
JHCHC's NOTICE OF PRIVACY PRACTICES
I acknowledge that I have received a copy of JHCHC's Notice of Privacy Practices, which describes how medial information about me may be used and disclosed and how I can get access to this information.
USE AND DISCLOSE OF INFORMATION
I understand that JHCHC will use and disclose my health information for the purposes of treatment, payment, and healthcare operalions. I undersland, acknowledge and consent to the release of my personal health information for the purposes outlined in this section, as described in the Notice of Privacy Practices which has been offered to me, and as may otherwise be permitted by law, I understand and acknowledge that JHCHC may record medical and other information related to my treatment in paper, electronic, photographic video and other formats and that such information will be used in the course of my treatment for payment purposes and to support healthcare operations. I give consent for my treating physicians and other health care providers to exchange information with other health care professionals and providers about my prior and current health conditions to facilitate treatment, I understand that telemedicine (defined as the use of medical information exchanged from one site lo another via electronic communications for the health of the patient, including consultative, diagnostic, and treatment services) may be employed to facilitate my medical care. All electronic transmission of data will be restricted to authorized recipients in compliance with the Federal Health Insurance Portability and Accountability Act (HIPPA) and applicable state privacy laws.
PATIENT RIGHTS AND RESPONSIBILITITES
I understand that I have the right, and the responsibility, to participate in my care and treatment. I understand that I have the right to be informed about the treatment being recommended, and the responsibility to ask questions if I do not understand it. I agree to provide accurate and complete information about my health history and presenting complaint, to agree upon a treatment plan, and follow that plan. I agree to participate and cooperate in my own care and treatment. I understand that my health care providers will treat me with respect, and I agree to do the same for them. Further information can be found in the Patient Rights and Responsibilities pamphlet, which has been offered to me.
RESPONSIBILITY FOR PAYMENT
In consideration of the services provided to me by JHCHC, I agree to pay JHCHC professlonals involved in my care for all services and supplies provided to me, If private health insurance, Medicare, Medicaid, other governmental or other insurance programs cover my treatment, I authorize JHCHC to bill any such insurer for all charges incurred by me in connection with my diagnosis, care and treatment. My insurance coverage may provide that some amount of the bill will remain my personal responsibility, such as my deductible, co-payment, co-insurance or charges not covered by my health insurance, Medicare, Medicaid or any other programs for which I am eligible. I understand that certain payments may be required at the time of, or in advance of, services being provided. I also understand I will be billed for any charges not paid by my insurer, and I will be responsible for paying them.
PATIENT CERTIFICATION
I HAVE READ, UNDERSTOOD AND FULLY AGREE TO the above General Consent to Diagnosis and Treatment. This consent shall go into effect upon my signature/electronic signature date and remain in effect as long as the above named patient utilizes JHCHC services, unless revoked in writing and submitted to JHCHC. I hereby sign my signature/electronic signature below as my free and voluntary act.