CONSENT AND UNDERSTANDING TO TREAT
Consent for Care:
I authorize Alaska Family Dermatology, LLC and any employee working under the direction of my dermatology provider to provide medical/surgical care and other services for me, or to this patient for whom I am the legal guardian. This care may include services and supplies related to my health (or that of the identified person) and may include (but are not limited to) preventative, diagnostic, therapeutic, maintenance, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes verbal or written contact and discussion with other health care professionals for my medical care and treatment.
Consent for Release of Information and Assignment of Benefits: I also authorize Alaska Family Dermatology, LLC to disclose any and all health information required to the identified insurance carrier(s) for any and all payment activities. I consent to assign all payments for services directly to Alaska Family Dermatology, LLC. I further consent to the use for any practice operational needs as identified in the Alaska Family Dermatology LLC Privacy Notice.
Consent for Medical Photography/Imaging: I give Alaska Family Dermatology, LLC permission to take clinical photographs for my medical record. I understand that the digital images remain the property of Alaska Family Dermatology, LLC. I understand that I may request a copy of my images, and that Alaska Family Dermatology LLC may charge a reasonable, cost-based fee to provide this service. I understand that use of my images for purposes such as marketing and professional education (e.g. use in professional publications and presentations) will require my advance written authorization if the images contain identifying information.
Consent for release of medication list through Surescripts:
I give Alaska Family Dermatology permission to obtain my medication list through Surescripts. Surescripts Medication History for Reconciliation delivers accurate dispensed medication histories provided by pharmacy benefit managers and pharmacies. The data aids in efficient medication reconciliation and helps reduce adverse drug events.
I have read and understand the Consents as stated above and agree to accept full responsibility as described above.