Appointment Consent

Appointment Consent Information

 

CONSENT TO RELEASE PHARMACY RECORDS:

I acknowledge and voluntarily consent to release to HealthCARE Express, information related to pharmacy records that shall include but are not limited to, prescription history, immunization records, pathology reports, and laboratory reports. I further understand and agree that this release shall apply to multiple and unaffiliated healthcare providers, insurance companies, and pharmacy benefit managers and that such information shall be viewable by providers and staff of HealthCARE Express. 

I expressly acknowledge that information obtained under this RELEASE may be considered as Protected Health Information (“PHI”) and may include information related to HIV/AIDS, mental health, drug/alcohol use, and treatment information and I hereby release such information to HealthCARE Express for diagnosis and treatment and health care services.

I understand the right to revoke this authorization, at any time, by sending a written revocation notice to HealthCARE Express at the following address:

HealthCARE Express 3515 Richmond Road Texarkana, TX 75503

Any revocation that is received shall not apply to the records that have already been received by HealthCARE Express under this RELEASE.  I understand that I may receive a copy of this RELEASE upon request to HealthCARE Express. I certify that I have read this form, or it has been read to me and I understand the contents of this RELEASE.

 

CONSENT FOR TREATMENT:

Healthcare Express and its employees evaluate and treat the patient for medical complaints and illnesses. This includes taking medical information, evaluation by physical examination, obtaining bodily fluids for laboratory testing, obtaining X-rays for diagnosis, administration of medications for treatment, and any other treatment or evaluation that may be necessary. If, at any time, I do not wish to have these services rendered, I may state so and they will not be provided, but an AMA form may need to be signed by the patient. All of my information will remain confidential. I acknowledge that I have been offered a copy of Healthcare Express Notice of Privacy Practices.

 

ASSIGNMENT OF BENEFITS:

I authorize the release of any medical information and payment of medical benefits to Healthcare Express for services necessary to process this claim and any future claims. I agree to be responsible for any deductible, co-insurance, co-pay, or any other balance not paid by my insurance.

FINANCIAL POLICY:

We are committed to providing you with the best possible medical care; if you have special needs, we are here to work with you. The following information is provided to avoid any misunderstanding or disagreement concerning the payment of professional services. PAYMENT IS DUE IN FULL AT THE TIME OF SERVICE: Co-payment will be collected before you are seen. Payment can be made by cash, check or credit card. If you have insurance that we do not participate with, our office will be happy to file the claim upon request; however, payment in full is expected at the time of service. If you have questions about your insurance coverage, we will be happy to assist you. Specific coverage issues should be directed to your insurance company. It is however, understood and agreed that the Responsible Party is responsible for all monies due for services rendered in the event insurance does not pay for these services. ALL CHARGES ARE AN ESTIMATE AND FINALIZED WHEN YOUR INSURANCE COMPANY PROCESSES YOUR CLAIMS.

If laboratory tests must be sent to an outside source for further evaluation, the responsible party understands they will be responsible for charges from that facility.

When visiting our facilities after hours, nights, and weekends a fee may be applied to the charges billed to your insurance company which is reasonable and customary in our contracts.

Providing your email and cell phone number will automatically register you for these forms of communication. Please let the front desk know if you would like to change these settings.

It is company policy to run your check by EFT or your credit card. For private pay (no insurance) all charges for the visit are due before you are seen. Please note that you may have a balance at the end of your visit, which must be paid before you exit the clinic. By signing, I agree that I have read and understand the terms of this agreement. 

AUTHORIZATION FOR RELEASE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION:

Your privacy is important to Healthcare Express. As a result, we ask you to complete the following authorization related to your personal health and health-related benefits.

I have read and understand the following statements about my rights:

• I may revoke this authorization at any time by giving written notice to Healthcare Express. I understand that my revocation will not affect any use or disclosure of my PHI that was made in reliance on the authorization before I revoked it.
• My health provider cannot require me to sign this authorization in order to be eligible for services or treatment.
• It is possible that the persons who receive information based on this authorization may disclose it to others and as a result, the information may no longer be protected by federal privacy rules.
• This Authorization for my personal health information does not apply to the release of the same information for any spouse or child that I may cover on my medical benefits or account at Healthcare Express. I understand that my spouse or child over 18 must provide independent Authorization for the release of their personal PHI. I acknowledge that I have received and signed a copy of this authorization.

AUTHORIZATION FOR RELEASE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION:

I acknowledge and understand that the information I provide Healthcare Express with regard to the Authorization to Leave Personal Health Information by Alternative Means will be kept in my medical record and the above parameters will be abided by until revoked by me in writing. It is my responsibility to notify HealthCARE Express should I change one or more of the telephone numbers listed above OR any one of the contact names.