Consent to Treat, Stop Cancer Now GA, LLC

Instructions: Please read carefully then initial and sign below

1. Consent for Treatment: I consent to diagnostic imaging that I am requesting for evaluation: the imaging studies are not being used to evaluate for any current symptoms, conditions or complaints but rather as a screening test for cancer. I consent to routine diagnostic and treatment procedures/examinations including, but not limited to injections, infusions of intravenous fluids, insertion of internal tubes, laboratory testing, administration of medications, radiographic procedures, assessments and treatments, monitoring considered reasonably necessary for the care and treatment of my condition by Stop Cancer Now GA, LLC including but not limited to those listed above. I understand that any Procedures involving material risks will be explained to me and that I will have the opportunity to ask questions concerning the associated risks, alternatives, and prognosis before allowing the Procedures to be performed. I consent to treatment and care provided by a team of healthcare providers, which may include mid-level providers such as physician assistants or advanced practice nurse practitioners. . I understand that Stop Cancer Now GA, LLC does not purport to interpret any imaging studies, that is done by an outside radiologist who is entirely separate from Stop Cancer Now. I understand that Stop Cancer Now GA, LLC will refer me to an outside imaging center which will employ individuals that are healthcare professionals to help facilitate having imaging tests limited to CT scans and MRI, and evaluation of kidney function and pregnancy status to facilitate these testsI consent to these individuals observing or participating in my Procedures for the purposes of relaying information to my primary care provider. I acknowledge that the practice of medicine is an inexact science and that no guarantees of assurances have been made to be regarding my Procedures at Stop Cancer Now GA, LLC or the results of such Procedures. I agree to cooperate fully with planning for my discharge. I agree to be discharged and/or transfer my care and follow up with my primary care provider who will manage any abnormal findings on my imaging. I agree to be under the care of my primary care provider after obtaining imaging studies to further monitor and evaluate any abnormal findings in the imaging tests ordered, or abnormal lab values regarding kidney function.

Limitation of Imaging in screening for cancer: I understand that the tests ordered and performed during this or following encounters by Stop Cancer Now GA, LLC cannot fully rule out a current or future cancer. All imaging tests have limitations, including but not limited to: cancerous lesions may be too early or too small to be visualized; cancer may be outside the imaged field (example soft tissue sarcoma of the thigh or an abnormal nodule of the thyroid gland), the type of cancer may not be able to be visualized on scans (example 1: hematological cancers such as leukemias, example 2: melanoma of the eye or skin, example 3 bile duct cancers), pre-malignant or malignant lesions may be better visualized directly by other screening tests (example 1: cervical cancers by Pap smear, example 2 polyps or masses by colonoscopy, example 3 pre-malignant or malignant changes of the esophagus or stomach by endoscopy). As such, I agree and understand that follow-up care with my primary care physician to continue routine examinations and preventative care and screening tests will be important.

Recommended Follow-up care and other: I understand that Stop Cancer Now GA, LLC highly recommends that you have health care insurance, life insurance, and primary care provider as this will be essential to obtaining follow-up care for non-cancerous lesions that require follow-up imaging and suspected/possible cancerous lesions that require follow-up testing and treatment. I understand that Stop Cancer Now GA, LLC does not provide any of this follow-up testing and treatment but only facilitates obtaining specific imaging studies. You are solely responsible for arranging and obtaining follow-up care for any findings on the imaging studies obtained. In addition I understand that Stop Cancer Now GA, LLC highly recommends that you obtain life insurance (if desired) prior to obtaining any imaging as the discovery of cancerous lesions may then make obtaining a policy difficult or impossible, and Stop Cancer Now GA, LLC is required to release any imaging studies to life insurance

4. Independent Contractors: I understand that some of the healthcare professionals providing Procedures, care, and services at Stop Cancer Now GA, LLC may be independent contractors, and are not agents or employees of Stop Cancer Now GA, LLC. Independent contractors are responsible for their own actions. Stop Cancer Now GA, LLC shall not be responsible for the independent contractors’ actions or failure to act.

5. Outside providers: I understand that some of the healthcare professionals providing and interpreting imaging studies that will be facilitated by Stop Cancer Now GA, LLC are separate entities, and are not agents or employees of Stop Cancer Now GA, LLC. Separate entities are responsible for their own actions. Stop Cancer Now GA, LLC shall not be responsible for these entities’ contractors’ actions or failure. These providers will have their own separate consent to treatment forms which will include risks of imaging studies including but not limited to MRI contrast, radiation from CT, etc. I understand that I should notify the imaging center and Stop Cancer Now GA, LLC of any allergies to contrast agents and/or pregnancy status.

6. Assignment of Benefits/Financial Agreement and Appointment of Representative: I authorize payment of benefits directly to Stop Cancer Now GA, LLC, with such benefits to be applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree to pay charges not paid under this assignment. I agree to provide Stop Cancer Now GA, LLC with all known payor information at the time that I submit payments for charges. In the event, I overpay Stop Cancer Now GA, LLC on a private pay account, I authorize Stop Cancer Now GA, LLC to apply such overpayment to satisfy any outstanding charges I owe for services I have received by a Stop Cancer Now GA, LLC facility or request for a partial or full refund. I understand charges made on my behalf are my responsibility to fulfill.

7. Consent for Disclosure of Information: I understand Stop Cancer Now GA, LLC is permitted to disclose health information about me for purposes of payment, my continued care or treatment, healthcare operations and otherwise in accordance with the Notice of Privacy Practice (separate document). Such disclosures may include, but are not limited to, disclosures of health information about me to my insurance company, healthcare plan, and any other payor or person or entity financially responsible for payment related to my treatment, disclosures to my referring or receiving healthcare provider, assisted living facility, ambulance service, or other treating provider or facility, and for services provided to me during or upon my discharge or transfer from Stop Cancer Now GA, LLC. If my health information contains information related to certain infectious diseases (including, without limitation, HIV/AIDS confidential information), substance abuse and/or mental health, I consent to the disclosure of such information by Stop Cancer Now GA, LLC only for so long as reasonably necessary to accomplish the legally permissible purposes described in the Notice of Privacy Practice (separate) and I waive any privileges with regard to such disclosures.

8. Telephone Consumer Protection Act Consent: I expressly consent to receive phone calls and text messages from Stop Cancer Now GA, LLC and its affiliates, and its affiliates’ service providers, agents, vendors, business partners, independent contractors and other third parties calling or texting on its or their behalf at any telephone number(s) that I provide or that they may obtain for me. To the extent not already covered above, I also expressly consent to receive such calls and texts from other “Covered Entities” and “Business Associates” as such terms are defined by HIPAA. I understand that I may revoke my consent at any time by notifying Stop Cancer Now GA, LLC through reasonable means.

9. Telemedicine: I understand and acknowledge that Stop Cancer Now GA, LLC operates by phone or video calls and there are no physical in-person consultations or examinations. I consent to this use of telemedicine by Stop Cancer Now GA, LLC and understand that the resulting information is used for performing ordering imaging studies, my care and treatment plan, and as otherwise permitted under HIPAA and patient privacy laws.

10. Permission to be contacted for Results: If you would like to change your preferences regarding being contacted about your imaging results or specify your preferred methods of being contacted, you can do this by emailing stopcancernowga@gmail.com. Results of imaging will be available to the you by email or if you prefer you can schedule a phone consultation to discuss results. You are solely responsible for arranging and obtaining follow-up care for any findings on the imaging studies obtained.