Tampa Urgent Care
Please read the following forms in entirety, signature is required at the bottom.
Consent to Treatment
I hereby give my permission to Tampa Urgent Care (Memon Health Associates) to give me medical treatment.
I allow the Tampa Urgent Care to file for insurance benefits to pay for the care I receive.
I understand that:
Tampa Urgent Care will have to send my medical record information to my insurance company.
I must pay my share of the costs.
I must pay for the cost of these services if my insurance does not pay or I do not have insurance.
I understand: I have the right to refuse any procedure or treatment.
I have the right to discuss all medical treatments with my provider
No Show Policy
We have noticed we have had several no-shows and last minute cancellations of appointments as of late. We ask that you show consideration by notifying our office at least 24 hours in advance if you are unable to keep your scheduled appointment. We would like to have the opportunity to offer that appointment to another patient who is sick or hurt and in need of seeing the doctor. Please be courteous and call if you cannot come for your scheduled appointment. Unfortunately, due to the number of patients who have cancelled at the last minute, or are no-shows for their appointment, we must institute a $25.00 cancellation fee for all no-shows, or last-minute cancellations.
All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments.
Assignment of Benefits
I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical plan, to issue payment check(s) directly to TAMPA URGENT CARE, medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.
Authorization to Release Information
I hereby authorize TAMPA URGENT CARE to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature
Medication History Download
I understand and I give my consent to retrieve and review my medication history. I understand that this will become part of my medical record. A medication history is a list of medicines that these providers and other healthcare providers have recently prescribed for a patient. It is collected from a variety of sources, including, a patient's pharmacy, health plans, and other healthcare providers.
Acknowledgement of Receipt of Notice of Privacy Practices
We are committed to protecting your privacy and ensuring that your health information is used and disclosed appropriately. This Notice of Privacy Practices identifies all potential uses and disclosures of your health information by our practice and outlines your rights with regard to your health information. Please acknowledge that you have received our Notice of Privacy Practices. I acknowledge that I have received a copy of the Notice of Privacy Practices.
HIPAA Privacy Rule of Patient Authorization Agreement
Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))
I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:
a basis for planning my care and treatment;
a means of communication among the health professionals who may contribute to my health care;
a source of information for applying my diagnosis and surgical information to my bill;
a means by which a third-party payer can verify that services billed were actually provided;
a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.
I have been provided with a copy of the Notice of Privacy Practices.
I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.
Privacy Rule of Patient Consent Agreement
Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))
I understand that:
I have the right to review this Practice’s Notice of Information practices prior to signing this consent;
that this Practice reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I’ve provided, if requested;
I have the right to object to the use of my health information for directory purposes;
I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this Practice is not required by law to agree to the restrictions requested;
I may revoke this consent in writing at any time, except to the extent that this Practice has already taken action in reliance thereon.
Patient Consent for Use and Disclosure of Protected Health Information
I hereby give my consent for Tampa Urgent Care(the Practice) to use and disclose my protected health information (PHI) to perform treatment, payment and health care operations (TPO).
With this consent, the Practice may call me or email me to my home or other alternative location and leave a message by voice, email or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and anything pertaining to my clinical care, including laboratory test results.
With this consent, the Practice may mail to my home or other alternative location any items that assist the practice in performing TPO, such as appointment reminder cards, patient statements and anything pertaining to my clinical care as long as they are marked “Personal and Confidential.”
By signing this form, I am consenting to allow the Practice to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the Practice has already made disclosures upon my prior consent. If I do not sign this consent, or later revoke it, the Practice may decline to provide treatment to me.
Consent to Obtain Patient Medication History
Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.
The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions.
It is very important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate. Some pharmacies do not make prescription history information available, and your medication history might not include drugs purchased without using your health insurance.
Also over‐the‐counter drugs, supplements, or herbal remedies that you take on your own may not be included.
I give my permission to allow my healthcare provider to obtain my medication history from
my pharmacy, my health plans, and my other healthcare providers.
I have read all the above information.