TO THE PATIENT: You have the right to be informed about your condition and the recommended surgical, medical, or diagnostic procedure so that you may make the decision whether to undergo a recommended suggested treatment plan. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the propriate treatment or procedure for any identified condition(s).

By signing this form, you indicate that:

You voluntarily request a physician or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), 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 you to seek care at this practice.

You intend that this consent is continuing in nature even after a specific diagnosis is made and treatment recommended.

You consent to treatment at this office, any other satellite office under common ownership, in your place of residence, or via telemedicine and video.

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

You understand that:

You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician/provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.

The same standard of care applies to telemedicine as applies to an in-person visit. You will not be physically in the same room as your health care provider during telemedicine services. You will be notified, and your consent will be obtained for anyone other than your healthcare provider present.

There are potential risks to using technology, including service interruptions, interceptions, and technical difficulties.

If the video conferencing equipment or connection is not adequate, your healthcare provider or you may discontinue the telemedicine visit and make arrangements to continue the visit.

You have the right to refuse to participate or decide to stop participating in a telemedicine visit. Your refusal will be documented in your medical record. Your refusal will not affect your right to future care or treatment.

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 HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

You understand that: 

Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice may condition receipt of treatment upon execution of this consent. The laws that protect privacy and the confidentiality of health care information apply to telemedicine

The practice reserves the right to change the privacy policy as allowed by law. The practice has the right to restrict the use of health information but the practice does not have to agree to

An indirect financial relationship permitted under Texas Occ. Code 102.001 exists between this clinic and certain pharmacies and laboratories, to whom you may be referred, for prescriptions and lab work.

You have the right to request services provided by other laboratories and pharmacies. You have the right to revoke this consent in writing at any time and all full disclosures will then cease.

Your consent will remain fully effective until revoked in writing.

I HEREBY PROVIDE INFORMED CONSENT TO URGENTCARE2U TO USE PHONE OR SEND TEXT MESSAGES TO CONFIRM APPOITNMENTS, ALSO TO LEAVE A VOICEMAIL WHEN REQUIRED. I HEREBY PROVIDE CONSENT TO REQUEST, VIEW, AND USE MY EXTERNAL MEDICAL AND PRESCRIPTION RECORDS FOR TREATMENT PURPOSES AND TO OPT IN FOR TEXT MESSAGES NOTIFICATIONS.

____Initial here if you authorize us to discuss your medical condition with a member of your family.

Please name the members allowed: _________

 

Treatment (including direct or indirect treatment by other healthcare providers involved with my care and requests to obtain or release medical records from other physicians or facilities as necessary); Obtaining payment from third party payer (e.g. My insurance company);

The day-to-day healthcare operations of Urgentcare2u practice, including sharing with third-party vendors, some of which may require separate consent;

You understand that the third-party vendors who ask for my PHI are legally obligated to abide by the requirements of the HIPAA and are required to maintain the security and confidentiality of my information. I understand that if I wish to optimize my experience and enhance the continuity of my care, I must voluntarily opt-in by providing express consent (below) to sharing my information with third- party vendors.

You have also been informed of and given the right to review and receive a copy of the Joint Notice of Privacy Practices, which includes a description of the use and disclosure of my PHI, and my rights under HIPAA. I understand that you may change the terms of this Notice from time to time and that I can always ask for a current copy of the Notice.

You understand that I can request restrictions on how my PHI is used and disclosed to carry out treatment, payment, and health care operation, and that you are then required to comply with this restriction.

I understand that I can revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date consent is revoked will not be affected.

Acknowledgment of Notice of Privacy Practices

I certify that I have received a copy of Urgentcare2u's Notice of Privacy Practices.

The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Urgentcare2u care operations. The Notice of Privacy Practices also describes my rights and the duties of Urgentcare2u with respect to my protected health information.

Urgentcare2u reserves the right to change the privacy practices at any time and I may obtain a revised copy by calling the office and requesting a copy to be sent in the mail or asking for one at the time of my next appointment.