AliVera Health P.C.
General Patient Consent and Membership Agreement
1. Consent for Medical Care
I consent to medically appropriate evaluation, treatment, preventive care, medication management, testing, referrals, and follow-up provided by AliVera Health P.C. and its authorized healthcare team.
Services may be delivered in person, by video or telephone, through secure messaging, or by review of submitted health information.
I understand that results are not guaranteed and that certain medications, procedures, or sensitive services may require separate consent.
2. Membership and Self-Pay Services
My membership is for medical services and excludes psychiatry, psychotherapy, and psychiatric medication management. Screening, safety assessment, and referral may be provided when appropriate.
AliVera does not bill insurance for services under this membership. Membership is not health insurance and does not replace insurance coverage.
I agree to the membership price, billing schedule, included services, exclusions, renewal, cancellation, and refund terms disclosed and accepted at enrollment. This consent does not authorize recurring billing unless those terms have been provided and accepted.
Medications, laboratory testing, imaging, and outside services may cost extra unless expressly included in my plan. Additional charges require advance disclosure and my approval. I retain applicable Good Faith Estimate and billing-dispute rights.
3. Card-on-File Authorization
I authorize AliVera and its payment processor to securely maintain the payment method I provide and charge my agreed membership fees, the $15 telehealth no-show fee described below, and additional services whose prices I separately approve.
I confirm that I am authorized to use the payment method provided. Payment details are entered through the secure payment system, not on this consent form.
I will keep my payment method current and will receive a receipt for charges. This authorization does not permit unspecified charges or waive my right to question a charge.
I may revoke future card charges by written notice to AliVera, allowing a reasonable processing period. Revocation does not remove properly incurred balances or itself cancel membership; cancellation follows my enrollment terms.
4. Telehealth and Appointment Policy
I consent to telehealth and understand that its limitations may require an in-person examination, testing, or urgent evaluation.
I will provide my actual physical location for each encounter and participate from a private, safe location. I will not participate while driving.
I will give at least 48 hours' notice to cancel or reschedule. A missed telehealth appointment without notice may result in a $15 no-show charge to my authorized card on file, separate from membership fees.
A late cancellation alone does not trigger this fee. Emergencies and documented technical difficulties will be considered. No fee applies when AliVera cancels or its technical failure prevents the visit.
5. Outside Medical Records
I permit AliVera to request, receive, review, and incorporate relevant outside records, test results, hospital summaries, specialist notes, and medication histories for my treatment and care coordination.
I permit relevant treatment information to be exchanged with my treating providers, facilities, laboratories, and pharmacies as allowed by law. A separate authorization will be obtained when required, including for specially protected information. This consent does not authorize access to psychotherapy notes.
6. Prescriptions and Pharmacy Communications
I permit AliVera to review my prescription history, use prescription-monitoring systems as permitted or required, send prescriptions electronically, and communicate with pharmacies about prescriptions, refills, and medication safety.
Prescribing and refills depend on clinical judgment and may require a visit, testing, monitoring, or outside records. No medication or refill is guaranteed. Psychiatric medication management is excluded from this membership.
7. Patient Responsibilities
I will provide accurate health information, including medications, allergies, pregnancy status, and relevant medical history, and report changes promptly.
I will maintain current contact and emergency-contact information, review messages, complete recommended follow-up, and communicate respectfully.
I understand that inaccurate information or missed follow-up may delay care or cause harm. If safe care cannot continue, AliVera may restrict services or end the care relationship with notice and transition arrangements as required by law.
8. Communications and Privacy
I permit care-related contact using the telephone, email, portal, and mailing information I provide, including appointment, prescription, result, referral, and billing communications.
I understand that ordinary texts and email have privacy risks and may request another communication method.
I acknowledge that AliVera's Notice of Privacy Practices has been provided or made available to me. Marketing, unrelated disclosures, and other uses requiring separate authorization are not authorized by this form.
9. Emergency Contact and Safety Permission
If reasonable attempts to reach me fail and critical results or urgent care instructions require prompt follow-up, I permit AliVera to contact the emergency contact listed in my patient record to help reach me and arrange needed care.
I also permit contact when there are concerns about my safety. AliVera may share only information relevant to the contact's assistance, as allowed by law. This does not give the contact unrestricted record access or medical decision-making authority.
For a serious and imminent safety threat, AliVera may contact emergency services or others able to help, as permitted by law, without delaying urgent action to complete a fixed number of contact attempts.
I may change or withdraw this permission in writing; disclosures otherwise permitted or required by law may still occur.
10. Examinations, Images, and Patient Rights
I may ask questions, participate in decisions, request a chaperone, or refuse an examination, test, image, or treatment. Refusal may limit the care that can safely be provided.
Clinically necessary photographs or images may be included in my confidential medical record. Public or marketing use requires separate authorization.
I have the right to respectful care, information about risks and alternatives, access to my records as permitted by law, and the ability to raise concerns without retaliation.
11. Emergencies and Outside Care
AliVera does not provide emergency services or continuously monitor messages. For a medical emergency, I will call 911 or go to the nearest emergency department.
Outside providers and facilities may bill separately. AliVera does not guarantee their availability, charges, or insurance coverage.
12. Acknowledgment and Duration
I have read and understand this agreement, had an opportunity to ask questions, and voluntarily consent to its terms, including card-on-file charges and the $15 telehealth no-show fee.
This general consent remains effective for 12 months unless revoked earlier or replaced. I may revoke it in writing for future care; revocation does not undo prior services or actions. Membership and payment obligations follow the accepted enrollment terms and applicable law.
My signature below applies to this entire agreement. An electronic signature is intended to have the same effect as a handwritten signature to the extent permitted by law.