Garden State Mobile Medicine LLC

67 Apple Street, Tinton Falls, J 07724

Office: (732) 314-7410 Fax: (732) 351-2062

 

 

CONSULTATION PATIENT AGREEMENT AND CONSENT

Garden State Mobile Medicine LLC

This is an Agreement between Garden State Mobile Medicine LLC ("Practice"), which has a mailing address 67 Apple Street Tinton Falls NJ 07751 and the patient or patient's legal guardian ("Patient" The physicians of Practice ("Physicians") agree to provide the Patient with the physical consultation ("Services") on the terms and conditions set forth in this Agreement.

1. Services. This Agreement is for non-emergency Services only, and Patient may need to visit his/her primary physician, the emergency room or urgent care after consultation has been completed.

2. Disclaimer. This Agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal law. It provides only the Services described herein. It is recommended that health care insurance be obtained to cover medical services not provided for under this direct primary care

3. Term. This Agreement will commence on the date it is signed by Patient and Practice below. Practice has a right to determine, whom, to accept as a Patient, just as Patient has the right to choose his or her physician

4. Privacy & Communications. Patient will receive Services on the grounds of Paterson Charter School for Science and Technology ("PCSST"), which must comply with the requirements of the Family Educational Rights and Privacy Act of 1974 as amended ("FERPA") and its implementing regulations. Practice and its Physicians will cooperate with PCSST in complying with its obligations to comply with FERPA, including any requirements to keep patient information private and confidential.

5.FERPA Consent. Patient understands and consents to Practice and Physicians receiving certain information, including personally identifiable information and any other educational records or information relevant to the rendering of a non-emergency physical care consultation, to Practice and its Physicians for purposes of providing the Services contemplated by this Agreement, in accordance with FERPA. Patient understands that Services will not be provided without his/her prior written consent.

5. Patient Understandings and Consent (Initial next to each bullet point): This Agreement is for as needed care consultation visit and is not a medical insurance agreement.

 

• I/my child do NOT have an emergent medical problem at this time.
• In the event of a medical emergency, I agree to call 911 first.
• This Agreement does not meet the individual insurance requirement of the Affordable Care Act.
• I/my child do NOT expect the Practice to prescribe any prescription medications or chronic controlled substances on my behalf.
• The Services provided are for a non-emergency sports physical consultation visit as needed for the school year of 2024 and 2025.
• The Services will be provided under the supervision of the staff in Paterson Charter School for Science and Technology
• I am waiving an ongoing relationship with Garden State Mobile Medicine LLC. I am not entitled to ongoing primary care services.
• I consent to the release of any educational records, including personally identifiable information, relevant to the rendering of a non-emergency physical care consultation, to Practice and its Physicians for purposes of providing the Services contemplated by this Agreement.

Patient (or Legal Guardian) Signature: