Your Signature Will Serve for All of the Following:
 
Consent: I hereby give consent for Grace Medical Home to provide necessary treatments discussed. I have received a copy of the Privacy Policy of Grace Medical Home and authorize use/disclosure of information tocoordinate and/or manage my care or the care of my child/children and any related services, receive paymentfor services and perform general healthcare operations.
 
Grace Medical Home may call my home or other alternative location and leave a message on voicemail inreference to any items that assist the practice in carrying out treatment, payment, and healthcare operations(TPO), such as appointment reminders and any calls pertaining to clinical care, including laboratory andradiology results, among others.
 
Grace Medical Home may mail to my home or other alternative location any items that assist the practice incarrying out TPO, such as appointment reminder cards, patient statements, school immunizations, and/orphysical exam forms; all correspondence will be marked “Personal and Confidential.”
 
Grace Medical Home may e-mail to my home or other alternative location any items that assist the practicein carrying out TPO.
 
I permit a copy of this authorization to be used in place of the original.
 
Financial Responsibility: I understand that there is an annual enrollment fee to become a patient of Grace Medical Home and a small service facility fee for office visits. I acknowledge that I am responsible for thesecharges.
 
Missed Appointment Policy: I understand that if I am not able to keep an appointment, I must call toreschedule. If I do not show up for 3 scheduled appointments without calling, I may be dismissed from being apatient with Grace Medical Home.