1. Authorization for Medical Treatment
Authorization for Medical Treatment. I do hereby acknowledge, agree, and give my consent for diagnosis, treatment, behavioral health treatment, dental treatment, as deemed necessary by Charles Drew Health Center, Inc. as indicated appropriate by my treating provider, their assistants and/or designees. This Authorization includes, but is not limited to, routine diagnostic procedures, outpatient and inpatient care, laboratory test, x-rays and other tests or procedures. I also authorize copies of the medical records to be released to other physicians and healthcare facilities as deemed necessary by any physician(s) or provider whose care I am under. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as result to examination and treatment received at this Facility. I acknowledge that my care is under the direction of my treating provider and the Charles Drew Health Center, Inc. facility will follow the instructions of my provider(s) in the position in said care.
2. Patient Care
I, the undersigned, agree to uphold my responsibilities to take charge of my health care, working with my provider and maintaining compliance with my providers designated care plan for my health and well being.
3. Personal Valuables
I accept full responsibility for all property in my possession. I understand that Charles Drew Health Center, Inc. maintains no responsibility for property that is personal and in my possession.
4. Duration and Scope
For in-person and telehealth services, I understand this agreement is valid for one year (12 months) from the date it is signed, unless I cancel it sooner. These agreements will apply to any care provided to the patient at any Charles Drew Health Center, Inc. locations during the above-mentioned timeframes, unless the care provided requires additional consents by law.
5. Physician and Staff Employment
Some providers at Charles Drew Health Center, Inc. may be independent contractors who use Charles Drew Health Center, Inc. facilities to provide care to their patients (“Contractors”). As such, these various independent contractors may submit bills for the professional services they provide separate from the bill Charles Drew Health Center, Inc. may submit. Contractors are responsible for their own actions and Charles Drew Health Center, Inc. is not liable for their actions or failure to act.
6. Assignment of Facility Benefits
I hereby assign all insurance benefits and/or Medicare/Medicaid benefits to Charles Drew Health Center, Inc. and authorize direct payment to facility. This payment includes all payments for charges incurred during treatment, visit and observation at all clinics for Charles Drew Health Center, Inc. I agree that I am responsible for the financial aspect of my healthcare and will maintain compliance for any and all insurance plans, Medicare/Medicaid and any self-pay and/or sliding fee details. A photocopy of this agreement shall be as valid as the original.
7. Assignment of Professional Benefits
I hereby assign all insurance benefits and/or Medicare/Medicaid benefits to all physician(s), therapist(s), and/or medical professionals providing services to me and authorize direct payment to physician(s) and therapist(s). I agree to pay for any and all charges not paid pursuant to this assignment. A photocopy of this assignment shall be as valid as the original.
8. Authorized Representative
I hereby authorize Charles Drew Health Center, Inc. and its facilities, its agents and representatives to act on my behalf to recover benefit claims, appeal adverse benefit determinations, and to take any action deemed necessary to obtain payment for services provided to me by said Facility(s).
9. Statement of Responsibility
I understand that I am financially responsible to Charles Drew Health Center, Inc. as the patient, guardian, and conservator or insured for all charges not covered by the above assignments or programs. Charges may include medical insurance deductibles, co-insurance out-of-pocket expenses.
10. Sliding Fee Discount Program Policy
Charles Drew Health Center, Inc. has a sliding fee discount program and I may ask about it at any time. There is an application process for sliding fee, and eligibility is based on family size, family income, and other special circumstances. I may request a sliding fee application at any time.
11. Self-Payment
I understand I may choose to not have Charles Drew Health Center, Inc. bill my and/or the patient’s insurance for a particular health care item or service provided to the patient, and instead choose to personally pay in full the cost of that health care item or service. To exercise this option, I must notify Charles Drew Health Center, Inc. in a timely manner, complete additional forms, and pay all applicable charges promptly and in full.
12. Authorization to Release Information to Insurance Company/Third Party Payer
I hereby authorize Facility(s), any authorized healthcare provider, including Veterans Administration or governmental hospital, any insurance company or other person, institution, or organization to release my medical records to any person, corporation, workers compensation carrier, governmental agency (or representative thereof) which is or may be, liable under any contract or governmental program to this Facility, the patient, or a family member for all or part of the Facility(s) charge. I understand that information from the telehealth service (including identifiable images or other medical information) cannot be released to researchers or anyone else without my written consent. This Facility will endeavor to protect the confidentiality of my health records, related to in-person and telehealth services. However, the Facility shall not be liable by reason of its release of said health records or any part thereof when responding in good faith to an apparently valid release. I authorize release of pertinent records to pharmaceutical companies as needed. I also understand I shall have access to all health information resulting from in-person and telehealth services as provided by law.
13. Non-covered Medicare/Medicaid Services
The Medicare and Medicaid Programs have certain charges that are excluded from coverage, including but not limited to: cosmetic surgery, non-medically related dental surgery, routine diagnostic workups, routine physical exams, and oral drugs. I acknowledge I am financially responsible for all charges incurred if my medical/dental chart indicates for any of the listed treatments or care as listed.
14. Shadowing and Observation
Some people involved in patient’s care may be medical, nursing, or other health care personnel in training. I consent to their participation. Other non-Charles Drew Health Center, Inc. staff members may observe the patient’s care. I will be informed of all people who will be present at any site during in-person or telehealth consultations. I will also be informed whether telehealth consultations will be or will not be recorded. I have the right to request that any of these individuals not participate in or observe the patient’s care and this request will not affect the patient’s care at Charles Drew Health Center, Inc.
15. Contact by Phone
By providing Charles Drew Health Center, Inc. with my land line and/or cell phone number(s), I give my express consent for Charles Drew Health Center, Inc., its contractors, agents, and collection agents to contact me at these numbers, or at any number that I later acquire, and to leave live or pre-recorded messages or to send text messages regarding accounts or services. I understand that for greater efficiency, calls may be delivered by an auto-dialer.
16. Advanced Instructions for Healthcare
I understand that I may indicate in writing (Advance Directives, i.e. Living Will and Durable Power of Attorney) my desire to receive, select, and/or define medical or surgical treatment or choose non-treatment Charles Drew Health Center, Inc. will recognize such instructions in accordance with Nebraska and/or Iowa State law and the Facility(s) policies if either both Advance Directive statement(s) are provided to the Facility(s) so that a copy is filed with any medical record.
17. Telehealth Consent
I understand that I have the option to schedule telehealth consultations and may meet with my provider using secure virtual technology. I retain the right to refuse telehealth services at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. If I decline telehealth services, in-person care will be provided as an alternative.