C O N S E N T
Medical Release:
The information I have provided is true and correct to the best of my knowledge. If in case the named person in case of an emergency could not be reached out, permission is granted to The Dr. Ala Stanford Center For Health Equity to make arrangements in securing proper treatment, including hospitalization, anesthesia, and other injections, x-rays, or any other operations that may be immediately be needed.
I hereby authorize to release reports necessary for insurance purposes for my Student above and likewise grant that the information found in this form may be copied for purposes that are deemed necessary for securing medical treatment.
I understand the Centers responsibility to make every effort to contact the Student's parent or guardian. I further understand that in case I do not have medical insurance, I will be responsible to shoulder all the costs of the medical expenses.
Liability Release:
It Takes Philly, Inc. (ITP) & Black Doctors Consortium (BDC), The Dr. Ala Stanford Center For Health Equity and its employees and volunteers collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voicemails, forms, and from the submission of applications that are either required by law or necessary to process applications or other requests for assistance through our organization. Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voicemails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence. We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that are considered patient confidential, restricted by law, or specifically restricted by a patient/client. Information is only used to provide you with health or counseling services which may require communication between ITP & BDC and health care providers, medical product or service providers, pharmacies, insurance companies, and other providers necessary to verify your medical information is accurate and determine the type of medical supplies or health care services you need. This is including, but not limited to, or to obtain or purchase any type of medical supplies, devices, medications, or insurance. If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law. We do not use cookies on our website to collect data from our site visitors. We do not collect information about site visitors except for one hit counter on the main index page www.blackdoctorsconsortium.com, www.bdccares.com that simply records the number of visitors and no other data. We do use some affiliate programs that may or may not capture traffic dates through our site. To avoid potential data capture that you visited a website, simply do not click on any outside affiliate links.