CONSENT TO TREATMENT FOR ALL PATIENTS

I hereby grant authorization and consent for medical treatment and/or procedures for myself or the patient for whom I am the legally authorized representative. I understand that no guarantee or assurance has been made as to the results that may be obtained.

PHOTO DOCUMENTATION

I hereby grant authorization for Homedica House Calls to make a copy of my photo identification to be included in my confidential record and take a digital picture for additional protection against the theft of my medical identity. I further grant authorization for the clinical staff to take photo documentation of any injury or procedure that they feel is medically necessary to include in my confidential medical record.  All photo documentation will be securely stored in your electronic medical record and will not be used for marketing or external purposes.

NOTICE OF PRIVACY PRACTICES

I acknowledge receipt of the Homedica House Calls Privacy Practices.

CARE MANAGEMENT SERVICES

I consent to participate in Care Management Services offered by Homedica House Calls.  These services may include, but are not limited to:

·        Chronic Care Management (CCM)

·        Behavioral Health Integration (BHI)

·        Advanced Primary Care Management (APCM)

·        Remote Patient Monitoring (RPM)

These services are designed to help manage my chronic conditions, improve care coordination, and enhance my overall health outcomes. By participating, I understand that the clinical staff will assist with coordinating care, including medication management, provider visits, and other healthcare resources and needs.  I understand that only one practitioner can provide and bill for these services during a calendar month, and that I may be responsible for applicable copayments or coinsurance for non-face-to-face services.

Revocation of Consent (Opt Out):
I understand that I have the right to stop participation in any of the Care Management Services (such as CCM, BHI, APCM, RPM) at any time.
To revoke my consent, I can notify Homedica House Calls in writing, by phone, or in person. My revocation will be effective at the end of the month in which I make the request, and I will not be billed for care management services in subsequent months after revocation.

TELEHEALTH CONSENT

I consent to the use of telehealth services, which may include audio, video, and other telecommunications technologies to deliver healthcare services. I understand that telehealth visits may not be appropriate for all conditions and that I have the right to choose an in-person visit instead.  I understand that telehealth visits are documented and billed similarly to in-person visits and may be subject to the same cost-sharing obligations.

INSURANCE ASSIGNMENT AND FINANCIAL RESPONSIBILITY

I hereby authorize the offices of Homedica House Calls to release any medical information required during the course of examination and treatment to my insurance, and I permit payment to Homedica House Calls from my insurance company for any benefits due for services rendered. I recognize and accept responsibility for services rendered regardless of insurance coverage. This includes, but is not limited to, coinsurance, copayment, deductible, and non-covered services.
I understand that I am responsible for all charges incurred, including those related to laboratory testing, radiology, medical supplies, etc., and agree to pay for services rendered by Homedica House Calls providers.

I have read and understand the above statements and hereby give Homedica authorization to act accordingly on my behalf. I understand that I may revoke any portion of this consent in writing at any time, except to the extent that action has already been taken.