NOTICE TO PATIENT/GUARANTOR: ASCENT EMERGENCY MEDICAL CENTER IS A LICENSED FREESTANDING EMERGENCY CARE CENTER. YOUR INSURANCE WILL BE BILLED FOR EMERGENCY ROOM SERVICES AND PHYSICIAN SERVICES. A COPY OF THIS FORM MAY BE MADE AVAILABLE TO THE PATIENT.
CONSENT TO TREATMENT
I consent to the procedures that may be performed during this visit including emergency treatment and/or services which may include, but are not limited to, laboratory services, x-ray examinations, diagnostic procedures, physician, nursing, or services rendered to me as ordered by my physician or other health care professional. I voluntarily request and consent for independently contracted physicians (via Ascent Emergency Medical Center, LLC.) to order all necessary tests and treatments while I am a patient at Ascent Emergency Medical Center, LLC. I understand that medical care is not an exact science and that no guarantee or warrantee is being made as to my examination, treatment, result, or outcome. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. However, I understand that doing so may hinder my treatment and/or medical outcome.
CONSENT TO USE AND DISCLOSE INFORMATION
I agree and consent to the use and disclose of my health information for the purpose of treatment, payment from third party payers, and other healthcare operations, such as the maintenance of medical records, communication of health information with primary care physician, referring physician or other healthcare professionals who contribute to my care, including quality peer reviews and assessments. I grant permission for Ascent Emergency Medical Center to take photographs, should the need arise, for purpose of my treatment during my health evaluation and treatment.
The Texas Department of State Health Services Texas Healthcare Information Collection (THCIC) program will receive patient claim data regarding services provided by Ascent Emergency Medical Center and Drew Emergency Physicians. The patient’s claim data is used to help improve the health of Texans through various methods of research and analysis. Patient confidentiality is held to the highest standard and your information is not subject to public release. THCIC follows strict internal and external guidelines as outlined in Chapter 108 of the Texas Health and Safety Code and the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
PRIVACY NOTICE ACKNOWLEDGEMENT
A copy of Notice of Privacy Practices has been made available to me as required by the Health Insurance Portability and Accountability Act. I understand that if I have questions or complaints, I may contact our corporate office.
ACCIDENTAL BODILY FLUID EXPOSURE TO HEALTHCARE WORKER
In the case of my bodily fluid exposure to a healthcare employee, I consent to testing, which may include, but not limited to, SARS-CoV-2, HIV or Hepatitis, to determine the presence of any communicable disease for the benefit of the exposed employee. I understand that these test results may only become a part of my medical record if it is required to report such results in order to comply with state law. I understand that I will be responsible for the charges for any such test.
SMOKING POLICY
To maintain the health and safety of patients, visitors, and staff, Ascent Emergency Medical Center is a strictly enforced smoke-free & vape-free environment. Ascent Emergency Medical Center and its associated entities are not responsible for any claim or harm arising from smoking, or from leaving the facility for the purpose of smoking or consuming tobacco products including e-cigarettes and vaping devices.
PERSONAL VALUABLES
Although the facility will make all reasonable efforts in safeguarding my valuables, I understand that Ascent Emergency Medical Center, LLC., is not responsible for the loss or damage of personal valuables.
LEGAL RELATIONSHIP BETWEEN EMERGENCY ROOM AND PHYSICIANS
I am aware that my doctor may have an ownership interest in Ascent Emergency Medical Center and that I have a right to seek medical treatment
elsewhere. A list of physician owners may be obtained upon request by the patient or legal guardian.
ASSIGNMENT OF INSURANCE BENEFITS
I assign Ascent Emergency Medical Center, LLC., all right, title, and interest in any and all health insurance and/or health plan proceeds/benefits from any plan(s) arising from the provision of any goods and services provided by Ascent Emergency Medical Center, LLC., and/or physicians/healthcare providers thereof. This assignment is made in accordance with §1204.054, Tex. Ins. Code.
I also assign and transfer to Ascent Emergency Medical Center, LLC. all rights, title, and interest in any claims against any health insurers, sponsors and/or plan administrators of any of my health benefit plan(s) arising from or pertaining to any wrongful acts and/or omission pertaining to any of said health/benefit plan(s) or health insurance policy(ies) including, but not limited to, claims for a non-payment or underpayment of health provider invoices and claims. I further expressly and knowingly assign all rights under my benefit plan and the Employee Retirement Income Security Act of 1974 to sue my benefit plan for any breach of its fiduciary duty. By executing this assignment of benefits, I am directing the health insurance carrier or other health benefit plan providing my coverage (including, but not limited to, any employers, employer group, or trust sponsored or offered plan), to pay Ascent Emergency Medical Center, LLC.
Ascent Emergency Medical Center, LLC. file primary and secondary insurance claims for insured patients. I authorize the facility and/or physicians indicated above to release medical information about me as may be necessary for the completion of my insurance claims for this occasion of service to any insurance carrier or health plan.