Consent and Release Forms

Medical Release Form
Patient Name*
Date of Birth*
SSN
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
StateZip Code
Phone NumberEmail
Pharmacy Name
Pharmacy Address
I hereby grant permission for you to release confidential health information about me, by releasing a copy of medical record, or a summary or narrative of my protected health information to Olive Health for
Patient Name*
Signers name*
Relationship to Patient (Patient, Parent, Guardian POA, Health Care Surrogate)*
Date*

MonthDayYear
Date
Signature*

Clear

Consent to Treat Form
1. I give permission for Olive Health, LLC to give medical treatment to
Patient Name*
2. I allow Olive Health, LLC to file for insurance benefits to pay for the care I receive.

Olive Health, LLC will have to send my medical record information to my insurance

company. I must pay my share of the costs. Imust pay for the cost of these services if my insurance does not pay or I do not have

I have the right to refuse any procedure or treatment. I have the right to discuss all medical treatments with my clinician.

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 or not 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. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, 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 this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing.

You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your healthcare provider, we encourage you to ask questions.

By affixing my signature below, I voluntarily request a physician, and/or mid level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s
I certify that I have read and fully understand the above statements and consent fully and voluntarily to
Signers Name*
Relationship to Patient (Patient, Parent, Guardian POA, Health Care Surrogate)*
Patient Parent Guardian POA Health Care Surrogate Signature*

Clear
Date*

MonthDayYear
Date

Medication List (please list out your meds or use the upload link below)

	Name of med	Dosage	Frequency	Special intructions
Med1
Med2
Med3
Med4
Med5
Med6
Med7
Med8
Med9
Med10

File Upload

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CHRONIC CARE MANAGEMENT (CCM) SERVICES CONSENT FORM

For Medicare Patients
Patient Information
Patient Name
DOB
Address
Phone
Emergency Contact
CONSENT FOR CHRONIC CARE MANAGEMENT SERVICES
Patient Name
I understand and consent to participate in Chronic

Care Management (CCM) services provided by Olive Health.
WHAT IS CHRONIC CARE MANAGEMENT (CCM)?
Chronic Care Management is a Medicare and insurance-covered service designed to help patients with multiple chronic conditions receive coordinated, comprehensive care

between office visits. CCM services include:

Care Coordination: Regular communication between your healthcare team

Medication Management: Review and monitoring of your medications Health Monitoring: Regular check-ins about your symptoms and conditions Care Plan Development: Creating and updating a personalized care plan 24/7 Access: Access to healthcare providers for urgent questions Specialty Care Coordination: Help managing referrals and specialist appointments

I understand that CCM services may include: Monthly phone calls or secure messaging to discuss my health status Review of my medications and potential interactions Coordination with specialists and other healthcare providers Development and updates to my comprehensive care plan Health education and self-management support 24/7 access to clinical staff for urgent questions Electronic health record management and care coordination
BILLING AND INSURANCE
CCM services are typically covered by Medicare and many insurance plans.

I understand there may be copays or deductibles associated with these services.

I authorize Olive Health to bill my insurance for CCM services

I am responsible for any amounts not covered by insurance.
Communication Preferences

Phone CallsText MessagesSecure patient portal messagingEmail
Communication Email
example@example.com
Communication Phone
PATIENT RIGHTS AND RESPONSIBILITIES

I can refuse CCM services at any time without affecting other care I can revoke this consent at any time by contacting the practice Ihave the right to a copy of my care plan I can request changes to my communication preferences

Participate actively in my care management Keep scheduled appointments and respond to outreach attempts Inform the care team of changes in my condition Update contact information when it changes

My health information will be protected according to HIPAA regulations Information may be shared among my care team members for coordination

Electronic communication carries some privacy risks, which have been explained to

I have read and understand this consent form. I have had the opportunity to ask questions about CCM services. I voluntarily consent to participate in Chronic Care Management services. I understand I can withdraw from CCM services at any time
Signature

Clear
Date

MonthDayYear
Date
Signers Name*

CONSENT FOR ELECTRONIC COMMUNICATION OF PROTECTED HEALTH INFORMATION (PHI)
Patient Name
Email
example@example.com
COMMUNICATION DISCLAIMERS

By providing your contact information, you consent to receive communications from Olive Health via text message, phone call, and/or email. Message and data rates may apply for text messages. Message frequency varies. Reply STOP to opt out of text messages or HELP for assistance. Standard calling rates may apply for phone calls. You can unsubscribe from emails at any time by clicking the "unsubscribe" link in any email. Your consent is not required as a condition of service.

CONSENT TO RECEIVE PROTECTED HEALTH INFORMATION VIA EMAIL

I understand that Olive Health, LLC may need to communicate with me about my healthcare, including sending medical records, test results, appointment information, and other protected health information (PHI) via email.

RISKS OF EMAIL COMMUNICATION

I acknowledge and understand the following risks associated with email communication:

Lack of Encryption: Standard email is not encrypted and may not be secure
Unauthorized Access: Email may be intercepted, forwarded, or accessed by unauthorized individuals
Misdirected Messages: Email may be sent to wrong recipients due to human or technical error
Storage Risks: Email may be stored on servers or devices that could be compromised
No Delivery Guarantee: There is no guarantee that email will be delivered or received

MY CONSENT

Despite understanding these risks, I voluntarily consent to receive my protected health information via email at the address listed above. I understand that:

I have the right to request alternative forms of communication at any time
I can withdraw this consent at any time by providing written notice
I am responsible for informing Olive Health of any changes to my email address
I should notify Olive Health immediately if my email account is compromised
Olive Health will make reasonable efforts to protect my information but cannot guarantee complete security

PATIENT RESPONSIBILITIES

I agree to:

Keep my email address current and notify Olive Health of any changes
Use a secure, private email account that only I can access
Not share my login credentials with others
Report any suspected unauthorized access to my email account
Understand that email should not be used for urgent medical matters

SCOPE OF CONSENT

This consent applies to communication between myself and:

Healthcare providers at Olive Health

PRIVACY POLICY

Overview

At Olive Health, we respect your privacy. This Privacy Policy explains how we collect and use your personal information when you submit an inquiry through our website.

Information We Collect

When you contact us through our website, we collect:

Your name
Phone number
Email address
Any additional information you provide in your inquiry
How We Use Your Information

We use your information to:

Respond to your inquiry
Follow up with you regarding your request
Provide you with information about our services
Send you periodic email communications about our products, services, and updates
Send you text messages related to your inquiry or about our services
You can opt out of receiving marketing emails at any time by clicking the "unsubscribe" link at the bottom of any email or by contacting us directly. You can opt out of text messages at any time by replying "STOP" to any text message or by contacting us directly.

We will not sell, rent, or share your personal information with third parties for marketing purposes.

Data Security

We take reasonable measures to protect your information from unauthorized access or disclosure.

Your Rights

You have the right to:

Request a copy of the information we have about you
Request that we delete your information
Opt out of future communications
To exercise these rights, please contact us at frontdesk@olivehealthfl.com

Contact Us

If you have questions about this Privacy Policy, please contact us:

Email: frontdesk@olivehealthfl.com
Phone: 813-417-4767

Changes to This Policy

We may update this Privacy Policy from time to time. Any changes will be posted on this page with an updated date.

By submitting your information through our website, you agree to this Privacy Policy.
By signing below, I acknowledge that I have read and understand this consent form and privacy policy, including the risks of email communication, and I voluntarily consent to receive protected health information via email, text message, and phone calls from Olive Health.
Signature

Clear
Date

MonthDayYear
Date
Signer Name
Should be Empty:

Medical Release Form

Consent to Treat Form

CHRONIC CARE MANAGEMENT (CCM) SERVICES CONSENT FORM

Patient Information

CONSENT FOR CHRONIC CARE MANAGEMENT SERVICES

WHAT IS CHRONIC CARE MANAGEMENT (CCM)?

BILLING AND INSURANCE

CONSENT FOR ELECTRONIC COMMUNICATION OF PROTECTED HEALTH INFORMATION (PHI)