I am voluntarily seeking medical care and/or treatment and consent the Weekend Clinic PLC to provide medical care to me. I give permission to the medical staff of the Weekend Clinic PLC to examine me, make diagnosis, and provide treatment to me in accordance with the information, explanations and recommendations they provide me.
I give my consent for the Weekend Clinic PLC to use and disclose protected health information (PHI) about me to carry out treatment, payment and health operations (TPO). The notice of Privacy Practices provided by the Weekend Clinic PLC describes such uses and disclosures more completely.
I have a right to review the notice of Privacy Practices prior to signing this consent. The Weekend Clinic PLC reserves the right to revise the notice of privacy practices any time. A revised notice of Privacy Practices may be obtained by forwarding a written notice to the Weekend Clinic PLC.
With this consent, the Weekend Clinic PLC may call my home, cell, or other alternative location and leave a message on voicemail or in person, text my mobile number, send mail or email in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and duties associated with clinical care, including lab test results, among others.
I may revoke my consent in writing to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent or revoke it later, the Weekend Clinic PLC may decline to provide treatment to me.