Home Physicians Group YOUR POST ACUTE SOLUTION, a Division of PCCFL
Primary Care Treatment and Services: I understand that I am consenting for Home Physicians Group to Treat and provide primary care services to me, including PCP (Primary care Physician), Mental Health (Psychiatry), Podiatry, and Pulmonary Services. Any visit is voluntary, and none of my rights to confidentiality or privacy are waived by my consent. I understand that refusal to consent to a Home Physicians Group visit will have no effect on the level or nature of Medicare/Medicaid benefits to which | am entitled to. Chronic Care Management: if eligible for services, HPG/Primary care of Central Florida is designated by me for purposes of providing CCM and for submitting claims for payment to Medicare or my Private insurance carrier for CCM services. I understand that CCM benefits are included in between Provider visits.
Patient Choice Acknowledgment:
In the event that I am hospitalized and need skilled nursing services, I request that my care be provided by Home Physicians Group/PC-CFL in all Skilled Nursing Facilities, Assisted Living communities, or at Home.
Student Engagement:
We value our students achieving their experiential training as Medical Practitioner and our company serves as a Preceptorship for medical students completing their residency programs. A student may be present during my visit.
Photographs and Video Release:
I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.
Release of Healthcare information:
I acknowledge and agree that HPG/PCCFL, Inc., may disclose my PHI and medical record information to the following individuals who are my family members, legal representatives, guardians, healthcare surrogates, caregivers, and/or have power of attorney on my behalf. (Please list all applicable names on Patient Registration.
Practice Policies:
By signing this form, you consent to our use and disclosure of protected information about you for treatment, payment, and/ or health care operations as described in this form. You have the right to revoke this consent in writing, except where we have already madea disclosure in reliance prior to your consent.
Notice of Privacy Practices:
We are required by law to protect and maintain the privacy of your health information, to provide this Notice about our legal duties and privacy practices and to abide by the terms of this Notice.
Insurance, No Show and Cancelation Policy:
Appointments cancelled with less than 24 hr notice may be subjected to a $50 fee. Patients who are not available for their confirmed visit without a call to cancel the appointment will be considered a NO SHOW subjected to a $50 fee. Medicare, Medicaid, or my private insurance will be billed for medical treatment and services rendered.
Consent for Use of AI Scribing Tools:
I acknowledge and consent to the use of AI-powered scribing tools to assist in the documentation, transcription, and summarization of conversations, meetings, or other communications. I understand that these tools use artificial intelligence to process and generate text and that their accuracy may vary.
By providing this consent, I agree that:
1. AI-generated transcripts or notes may be reviewed for accuracy and completeness.
2. The use of AI scribing tools does not replace professional judgment or human oversight.
3. I retain the right to request modifications, corrections, or deletion of any AI-generated content as appropriate.
4. The confidentiality and security of the information processed by the AI tools will be maintained in accordance with applicable privacy policies and regulations.
I understand that I can revoke this consent at any time by providing written notice.