Rights and Responsibilities

Patient's Name*

I will promptly supply all information requested by Access Now. If I see a doctor or receive care in a hospital and am asked to provide any additional information and/or complete any additional paperwork, even though I have an Access Now card, I will provide this information as requested.*

I agree

I authorize all individuals and entities to share my medical and financial information with Access Now.*

I agree

I authorize Access Now to share my financial and medical information with medical clinics, doctor’s offices and hospitals to coordinate my treatment.*

I agree

I will notify Access Now and my primary care clinic if my income changes or if I become covered by an insurance plan (including Medicaid/Medicare). I understand that failure to do so may result in disenrollment from the program.*

I agree

I will keep all appointments with Access Now specialists or cancel an appointment at least 24 hours in advance.*

I agree

I understand that if I miss any two appointments, consecutively or not, without appropriate advance notice, I will be disenrolled from Access Now and no services will be available to me any longer.*

I agree

I will present my Access Now identification card to the physician’s office at the time of my appointments.*

I agree

I will behave appropriately while at and in communication with the physician’s office and understand that failure to do so will result in disenrollment from Access Now.*

I agree

I will follow my doctor’s treatment plan, including taking prescribed medications.*

I agree

I will return to my primary care clinic prior to the expiration date on my enrollment card if I need continued or additional care.*

I agree

I understand that if I receive a bill related to Access Now services I need to call 804-622-8145 to report the bill to Access Now.*

I agree

By signing below, you indicate that you understand and agree to all patient rights and responsibilities in this document.*

Signature

Date*

Date

I am currently seeing a doctor through Access Now.