If yes, please indicate your secondary health plan coverage information below:
7.Have you been in close contact with:
By signing this document you agree that we may give you your test results by text or voice mail at the phone number or by email at the email address listed on your Patient Registration Form. You further acknowledge that Ascent EMC is not solely a COVID testing center. We are an emergency room that offers COVID testing and evaluations.
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.
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.
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.
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.
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.
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.
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.
There is no physician ownership of this facility at this time.
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.
Ascent Emergency Medical Center, LLC. is NOT a participating Medicare or Medicaid provider. Medicare / Medicaid beneficiaries will be charged the time-of-service fee schedule for prompt-pay patients for any treatment or services rendered during length of stay at this facility. ADVANCED NOTIFICATION: Ascent Emergency Medical Center will not file a claim to Medicare or Medicaid. Medicare and Medicaid recipients may be personally responsible to Ascent Emergency Medical Center for charges incurred while receiving treatment or care at Ascent Emergency Medical Center.
Ascent Emergency Medical Center, LLC. Is an “out-of-network” provider with all insurance and/or health benefit plans. I understand that my out-of-network payment responsibility may be higher than an in-network option. Texas Insurance Law states that if a condition is deemed a medical emergency, insurance will pay in accordance with the plan’s benefits of the services at the “in-network” benefit level, but not all emergency room services are medical emergencies.
I understand that physicians (Drew Emergency Physicians, PLLC, consulting physicians), or healthcare providers rendering services to me while at Ascent Emergency Medical Center, LLC. may bill separately. I understand that physicians or healthcare providers providing services while at Ascent Emergency Medical Center may not be participating providers with the same third-party payers or benefit plans. I understand that my facility bill is inclusive of laboratory and radiology services provided to me during my length of stay. I understand that if a consulting physician is used during the course of treatment rendered to me that I will be duly informed and will be responsible for any charges incurred for such consultation physician services. I understand that I am responsible for paying all providers subject to the terms of my health plan or insurance, if any.
I agree, whether signing as agent or a patient, that in consideration of the services to be rendered, I hereby am responsible for paying facility copayments, deductibles, estimated facility coinsurance amounts, and any balances deemed not to be a covered benefit of the insurance policy. These payments may be due AT TIME OF SERVICE. Monthly statements will be sent to guarantors for patient balances. Acceptable means of payments are cash, money order, cashier’s check, credit card, or personal checks. I further understand that if I am evaluated by a physician other than the attending emergency room physician that I may be billed for those physician services.
Self-pay balances must be paid in full prior to discharge. If the balance due is referred to a collection agency or attorney, I understand that there may be additional fees, interest, and expenses that I will be responsible. Questions regarding your bill may be directed to:
F & A Medical Billing at (469) 301-0816.
If any of the provided services are not covered by my insurance company, or if Ascent Emergency Medical Center, LLC. is not able to verify eligibility, I am responsible for all charges incurred for services rendered.
I have read, understand, and accept the consents, policies, and terms as set forth above. All above information provided is true to the best of my knowledge. A copy of the HIPAA notice and HB2041 Disclosure has been made available to me.
The physicians, nurses, and entire staff are committed to assure you safe, reasonable care.
A patient has the right, upon request, to be given the name of his attending practitioner, the names of all other practitioners directly participating in their care and the names and functions of other healthcare professionals having direct contact with the patient.
A patient has the right to consideration of privacy concerning their own medical care program. Case discussions, consultation, examination, and treatment are considered confidential and shall be conducted discreetly.
A patient has the right to have records pertaining to their medical care treated as confidential, except as otherwise provided by law or third-party contractual arrangement.
A patient has the right to know what facility rules and regulations apply to his conduct as a patient.
A patient has the right to expect emergency procedures to be implemented without necessary delay.
The patient has the right to good quality care and high professional standards that are continually maintained and reviewed.
The patient has the right to full information in layman’s terms; concerning diagnosis, treatment & prognosis, including information about alternative treatments and possible complications. When it is not medically advisable to give the information to the patient, the information shall be given on their behalf to their designee.
Except in emergencies, the practitioner shall obtain the necessary informed consent prior to the start of a procedure. Informed consent is defined in Texas Administrative Code, Title 25, Part 7m Chapter 601.
A patient, or if the patient is unable to give informed consent, a responsible person, has the right to be advised when a practitioner is considering the patient as part of a medical research program or donor program, and the patient, or responsible person, shall give informed consent prior to actual participation in the program. A patient, or responsible person, may refuse to continue in a program to which he has previously given consent.
A patient has the right to refuse drugs or procedures, to the extent permitted by statute, and a practitioner shall inform the patient of the medical consequences of the patent’s refusal of said drugs or procedures.
A participant has the right to medical and nursing services without discrimination based upon age, race, color, religion, sexual orientation, national origin, handicap, disability or ability to make payment.
The patient who does not speak English should have access, where possible, to an interpreter.
The facility shall provide the patient, or patient designee, upon request, access to information contained in their medical records unless access is specifically restricted by the attending practitioner for medical reasons.
The patient has the right to expect good management techniques to be implemented with the facility. Those techniques shall make effective use of the time of the patient and avoid the personal discomfort of the patient.
When an emergency occurs and a patient is transferred to a hospital, the responsible person/patient’s designee shall be notified. The institution to which the patient is to be transferred shall be notified prior to the patient’s transfer.
The patient has the right to expect the facility to provide information for continuing health care requirements following discharge and the means for meeting them.
A patient has the right to be informed of his rights at the time of admission.
The facility expects the patient to ask questions about any directions or procedure they do not understand.
The facility expects the patient to be considerate of other patients and staff in regard to noise, smoking, and number of visitors in the patient areas. The patient is also expected to respect the property of the facility and other persons.
The patient is expected to follow instructions and medical orders and report unexpected changes in their condition to their physician and facility staff.
The patient is expected to follow all safety regulations that they are told or read about.
If the patient fails to follow their healthcare provider’s instructions, or if the patient refuses care, they are responsible for their own actions.
The patient has the right to ask the ER to honor their Advanced Directive.
The patient has the right to be free from all forms of abuse, neglect, exploitation, or harassment.
A copy of my patient rights and HIPAA have been made available to me. I understand that I am entitled to a copy of this form upon request. Should you have a complaint or grievance please contact the Administrator at (713) 574-1166.
Presentation of a complaint shall not compromise care. If your complaint or grievance is not resolved to your satisfaction, you may contact the Texas Department of State Health Services, Health Facility Compliance Group (MC 1979) PO Box 149347, Austin, TX 78714-9347 TDSHS/HHS Complaint Hotline: (888) 973-0022