"Our aspiration is to encompass healthcare services that permits all individuals access to efficient care"

I hereby give my consent to my Medical Provider at S&K Primary Care, LLC, and his/her designated healthcare provider for the evaluation, diagnostic (s), testing, and treatment. I understand I may request and receive information on the specific affiliation (s) of any healthcare provider I encounter during my

I understand that protected health information (PHI) may refer to medical or health information, including prognosis, psychological or mental illness, prescription, laboratory, and other medical results, tests or diagnosis.

I give my consent for the release of my PHI for the purpose of treatment, payment, and other relevant healthcare operations.

I understand that I have the right to discuss all of my medical treatment (s) with my provider. I have the right to refuse any procedure or treatment.

I understand that I shall be financially responsible for all treatments and services provided by S&K Primary Care, LLC. I understand that S&K Primary Care, LLC will not submit a claim for insurance benefits to pay for the care I receive. I understand that if I have insurance, it is my responsibility to contact my insurance company for reimbursement of services paid for. 

Photograph Consent

I hereby give my consent to the taking of my photograph for the purpose of identification for treatment if necessary, or for the purpose of identity for records and/or payment purposes. These photographs shall be kept by S&K Primary Care, LLC for the incidental purpose as it may be deemed necessary for the processing of my information.

I hereby declare that I am of legal age and mentally capable of giving my consent. I have had the opportunity to ask questions and clarifications, and by which I have received answers to my satisfaction.

The purpose of this Telemedicine Informed Consent is to get permission from the patient to use the telehealth services for treatment.

1. I understand that the laws that protect privacy and the confidentiality ofhealthcare information apply to telemedicine services.

     a.Confidentiality: Adequate and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine services. All existing confidentiality protections under federal and Tennessee State law apply to information disclosed during the telemedicine service.

2. I understand that there is a potential risk to using technology, including service interruptions, and technical difficulties.

     a. If it is determined that the video equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.

3. I understand that the telemedicine visit standard of care will be similar to a regular physical medical visit.

4. I understand that medical history and test details may be discussed with other professionals. I understand that I may be contacted via video and audio during the telemedicine appointment/visit. Video, audio, or any other digital photo of the patient can be recorded during the telemedicine visit for treatment purposes only.

5. I understand that this document will become a part of my medical record.

6. I understand that I have the right to withdraw the consent or permission to telemedicine consultation/treatment at any time.

7.I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.

8. I understand that services offered through S&K Primary Care, LLC are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care clinic.

By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents. I have had my questions answered to my satisfaction, and the risk, benefits, and alternatives to telemedicine visits shared to me in a language I understand. I am located in the state of Tennessee and will be in Tennessee during my telemedicine visit (s).

     The notice of Privacy Practices provides information on how we use or disclose protected health information.

This notice describes your rights under the law. By signing this agreement, you acknowledge that you have reviewedthe notice before signing your consent.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), allows for the use of information for treatment, payment or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in publications. You have the right to revoke this consent in writing, signed by you. However, sucha revocation will not be retroactive.

By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The Practice has the right to change the Privacy Police as allowed by law.
• The Practice has the right to restrict the use of information, but the Practice does not have to agree to those restrictions.
• I have the right to revoke this consent in writing at any time, and all full disclosures will then cease.
• The Practice may condition receipt of treatment upon execution of this consent. 

I have received, read and understand S&K Primary Care, LLC’s Notice of Privacy Practices containing a complete description of the uses and disclosures of my health information in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  I understand that this organization has the right to change its Notice from time to time, and that I may obtain a revised copy by contacting the office.

I understand that:

• I may request restriction of how my private information is used or disclosed, but the Practice does not have to agree with those restrictions.
• I may revoke the consent in writing at any time, and all future disclosures will cease.
• The Practice may condition treatment upon the submission of this consent.

 

Payment is due in full at the time of the scheduled appointment.

In the event of a no call/no-show or cancellation made less than 24 hours in advance, S&K Primary Care LLC reserves the right to charge a fee per our cancellation policy.

We understand that a situation may arise that could force you to cancel or postpone your appointment. Please understand that such changes affect not only our staff but our other patients as well, and we, therefore, request your courtesy and concern. If you need to cancel your appointment, please allow 24 hours to notify us of the cancellation. Should we receive less than 24 hours of notification, or should you fail to keep your scheduled appointment, you AUTHORIZE S&K Primary Care LLC to charge:

New Patient: $25.00

Established Patient: $15.00