Supportive Healthcare / Medical House Calls

Thank you for choosing Supportive Healthcare for your primary care needs. Our goal is to provide exemplary care in the place you call home. For us to provide these services, consents & financial responsibility must be obtained. Please read each section fully before initialing and signing the consent page. We look forward to knowing you.

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended, however your primary care is our first priority. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate medically necessary treatment and/or procedure for any conditions we may identify through the course of care.

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended and (2) you consent to treatment at your home or any institution at which you maintain a residence, whether short or long-term. You have the right to discontinue services by our practice at any point.

You have the right to discuss the treatment plan with your healthcare provider including the purpose, potential benefits or risks, and long-term strategies involved in your care. If you have any questions regarding any treatment plan recommended by your provider, we encourage you to speak up.

I voluntarily request a physician and/or nurse practitioner, physician assistant, or clinical nurse specialist (as well as other health care providers to provide reasonable and necessary medical examinations, testing, and/or treatment for the conditions for which I sought care. I understand that if additional testing or procedures are recommended, I will be asked to read and sign an additional consent form specific to that test or procedure.

I understand that patients can stop using telehealth services at any time by notifying a member of the Medical House Calls team (513-699-9090).  I understand that certain services are offered via telehealth and that anyone virtually or physically present during a telehealth visit with a patient may receive Patients personal health information.

Supportive Health Care may communicate with patients about their care using email or text messaging. These communications may not be secure and could be assessed by unauthorized third party.

As part of your care plan, we will need your authorization to obtain your medical records. This will help our team of clinical professionals have a comprehensive understanding of your medical history and needs. Please check the Medical Records Request box in the Consent To Treat section below for your approval.

Thank you for choosing Supportive Healthcare as your provider. Providing excellent care is what we are here for and in order to continue providing this service to our patients, financial responsibility must be established. The following policy must be read and agreed to prior to services.

Supportive Healthcare is able to provide medically necessary services to you by ensuring payment in a timely manner. In order to provide these services and ongoing support, we expect our patients to understand and abide by the established policies and procedures including this patient financial responsibility statement.

You are ultimately responsible for all payment obligations stemming from your treatment and care, thus guaranteeing payment for these services. You are responsible for any deductibles, copayments, coinsurance, or non-covered amounts applied to you by your insurance carrier or our policies.

You are responsible for knowing and understanding the benefits provided to you by your insurance carrier. Knowing whether a provider is in-network, requires prior authorization, or even needs a referral will be solely your responsibility. Any denial for reasons such as this will be transferred to you for payment. If your health coverage has changed or expired, it is your responsibility to alert our offices at 513-699-9090 to give the updated information or make payment arrangements.

By signing the consent signature page, you are agreeing to provide insurance information and allowing Supportive Healthcare to bill and collect payments on your behalf from your insurance carrier. You agree to facilitate the processing of your claims with your insurance should additional information be required or requested. In the event that additional information is not received to process your claims, the balance will be transferred to you and your account treated as self-pay. You further authorize Supportive Healthcare to release information acquired in the course of your treatment and care, including any medical records, notes, tests, diagnostic imaging, labs, or other documents related to this care, where it is necessary to process these claims.

Should incorrect information or omission of information result in untimely filing of claims according to insurance carrier guidelines, these balances will be transferred to you for payment.

Any non-covered or cost sharing amounts due from you once your insurance processes your claims will be billed to you via statement (whether text, electronic, or paper). Timely payment is expected upon receipt of this statement.

 

Supportive health Care is required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This Notice of Privacy Practices applies to the following organizations.

Supportive Healthcare

4850 Smith Road, Suite 250

Cincinnati, OH 45212

513-699-9090

www.supportivehc.com

info@medicalhousecallsllc.com

Patient acknowledges that they have received a copy of this notice and understand their rights within.

Thank you for choosing Supportive Healthcare for your primary care services. Our goal is to provide exemplary care in the place you call home. In order for us to provide these services, consents & financial responsibility must be obtained.

I attest that I have received, read and fully understand the following and consent to them fully and voluntarily.