CONSENT TO MEDICAL CARE AND TREATMENT:
I am being treated at NeuroX Health office online clinic ("Physician Office"), and I consent to all medical and surgical care, examinations and tests determined by the Physician Office to be necessary for me. Though I expect the care given will meet customary standards, I understand there are no guarantees concerning the results of my care. I assume full risk and responsibility and release the Physician Office and any individual provider from responsibility for things that might go wrong if I do not receive the medical care and treatment recommended to me. I understand that if an employee, physician, or affiliate of NeuroX becomes contaminated with my blood or body fluids through any type of exposure, that I may be tested for the Hepatitis Virus and/or the Human Immunodeficiency Virus (HIV), which causes Acquired Immune Deficiency Syndrome (AIDS).
CONSENT TO USE OF INFORMATION
Electronic Health Records:
I understand that the Physician Office may collaborate with other health care providers to coordinate, manage, and provide health care to me and I consent to the Physician Office's sharing my health information and records electronically for the purposes of treatment, payment or operations, including improving the overall quality of health care services provided to me (e.g., avoiding unnecessary or duplicate testing. etc.). I consent to the inclusion in the electronic health records of sensitive diagnoses and related information such as HIV/AIDS status, sexually transmitted diseases, genetic information, and mental health and substance abuse, etc. The electronic health records (EHR) will be accessible by NeuroX credentialed physicians/practitioners as well as other individuals approved to access the EHR for purposes related to treatment, payment, health care operations, and/or other purposes permitted by federal and state laws, including the Health Insurance Portability and Accountability Act ('HIPAA"). The Physician Office has implemented administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of my medical information as required by HIPAA.
Use and Disclosure of Information:
In addition to the above consent to use and share my health information with the NeuroX EHR system, I agree that the Physician Office may use and disclose my health information for a range of purposes including: treatment, eligibility verification, and/or payment to private and public payers or their agents including insurance companies, managed care organizations, my employer (if I am injured at work), state and federal government programs, Workers' Compensation programs, obtaining pre-admission or continued length of stay certification, quality of care assessment and improvement activities, evaluating the performance of qualifications of physicians and health care workers, conducting medical and nursing training and education programs, conducting or arranging for medical review, audit services, ensuring compliance with legal, regulatory and accreditation requirements and public health and health oversight services.
Request for Information from Others:
I consent to the Physician Office's request of my health information from other providers of care to me. receipt of and release of my health information, whether written, verbal, or electronic, for the uses described above as well as the Physician Office's participation in the health information exchange described in the Physician Office's Notice of Privacy Practices (NPP). Please refer to the NPP for additional, detailed information regarding the uses and disclosures of protected health information.
ASSIGNMENT OF BENEFITS:
I hereby assign to and authorize payment of all insurance and health care benefits available to me directly to the Physician Office for services provided to me. I understand that benefits may be payable to me directly if I do not provide this authorization.
I understand and agree that I am financially responsible for payment of all charges incurred which are not paid by insurance or health care benefits, including any and all products provided or services rendered to me which are not eligible for payment (non-covered) under health care plans, Medicare, Medicaid or other insurance or payers (e.g., services rendered by health ere providers who do not participate with my insurance plan). Non-covered services also may include those services my physician determines to be medically necessary, but are later determined unnecessary by the payer.
I understand that the Physician Office does not accept responsibility for any lost, stolen or damaged personal items while I am at the Physician Office.
In order to provide for your safety and a correct medical record, Neurox Health Physician Partners requires photo identification at the time of registration. I consent to photography or videotaping for my identification, care and treatment. Those images will be retained in my medical record by NeuroX in accordance with their policies.
PLEASE NOTE ONLY THE PATIENT AND/OR THEIR LEGAL REPRESENTATIVE SHOULD SIGN THIS FORM.
WE REQUIRE A COPY OF ALL LEGAL DOCUMENTS REGARDING GUARDIANSHIP AND CUSTODY