If minor: Name of Parent/guardian 1: First Name Last Name Name of Parent/guardian 2: First Name Last Name
Emergency contact: First Name Last Name Area Code Phone Number
Welcome to our practice.
At this point in your care, no specific treatment plan has been recommended, until we have had the opportunity to identify your needs. This consent form is simply to obtain your permission to perform the evaluation necessary to identify any condition that might require an appropriate treatment and/or procedures as part of your plan of care. You have the right to be informed about any condition identified and the options for recommended surgical, medical or diagnostic procedure to be used. You may then decide whether or not to undergo any suggested treatment or procedure, after being informed of the potential benefits and risks involved. The practice of medicine is not an exact science and no guarantees have been made to you as to the result of treatment for examinations at Spring Tide Family Health.
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that you understand that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended, along with potential risks and benefits. The consent will remain fully effective until it is revoked in writing. You have the right at any time to ask additional questions or to discontinue or decline services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your healthcare provider, we encourage you to ask questions.
Telemedicine (defined as the use of medical information exchanged from one site to another via electronic communications for the health of the patient, including consultative, diagnostic, and treatment services) may be employed to facilitate my medical care. All electronic transmission of data will be restricted to authorized recipients in compliance with the Federal Health Insurance Portability and Accountability Act (HIPAA) and applicable state privacy laws.
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents
We are committed to providing you with the best possible care, and we are pleased to discuss our policies related to insurance and fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy or your financial responsibility. The following is our policy for accepting insurance and procedures for payment in the event that you no longer have insurance coverage including Medicaid coverage.
By understanding your insurance coverage, you can help your doctor recommend care that is covered in your plan. Spring Tide, PLLC will try to be familiar with your insurance coverage so we can provide you with covered care. However, there are so many different insurance plans that it’s not possible for your doctor or our staff to know the specific details of each plan
In some cases, your doctor might decide that you need medical care that is not covered by your insurance policy. Insurance companies determine what tests, therapies and services they will cover. Your insurance company’s choices may mean that the test, therapy or service you need isn’t covered by your policy.
Assignment of Benefits
I permit Spring Tide, PLLC to bill my insurance company, if any, for services rendered and to send the necessary reports, including my medical information, for payment of services. I accept financial responsibility for the patient responsibility portion of the fees.
We maintain a record of the health care services that we have provided to you. We will share this information, as permitted by law, to provide your medical treatment, run our organization, and bill for these services. You have the right to view, obtain a copy, or amend the record if needed.
Our Notice of Privacy Practices is available at the front desk and on our website, springtidefamilyhealth.com. It describes in more detail your rights to your health information and how this information may be used and disclosed. Sharing of your health information is typically used to improve the continuity of care that you receive. Common examples include, but are not limited to, the following: sending immunization records to our state registry, use of a Health Information Exchange (HIE) with other health care organizations involved in your care, and accessing your prescription history from pharmacy benefits. If you have questions or want to discuss options for decreased information sharing, please contact us.
By signing below I acknowledge receipt of the Notice of Privacy Practices. This form must be signed by a parent or guardian if the patient is under the age of 18.
With this consent, I also agree that Spring Tide, PLLC may: Call or text the number(s) on file and leave a detailed message for the purpose of treatment, payment or health care operations (TPO). Mail to address(es) on file for the purpose of treatment, payment or health care operations. E-mail to the e-mail address on file for the purpose of TPO.