VISTA COMMUNITY CLINIC ASSIGNMENT OF BENEFITS: I authorize VCC to submit claims to my insurance and for my insurance company to pay benefits directly to VCC. VCC will charge patients at the usual and customary rate prevailing in this area. Health services will be provided at no charge to persons unable to pay for services. Persons will be charged for services to the extent that payment will be made by a third party authorized or under legal. VCC will not discriminate against any person receiving health services because of their inability to pay for services, or because payment for the health services will be made under Part A or B of Title XVIII ("Medicare") or Title XIX ("Medicaid") of the Social Security Act. VCC does not discriminate against any person on the basis of race, color, national origin, or on the basis of disability, sex, sexual preference, marital status, religion, or age.
AUTHORIZATION TO RELEASE INFORMATION: I consent to allow VCC to use and disclose my protected health information (PHI) within VCC, to carry out my treatment, to obtain payment, and carry out health care operations. My PHI may be disclosed to my health plan and /or its agents as necessary to verify benefits, authorize services, and process claims. My PHI may be disclosed to outside agencies or institutions involved in my continuing care when I am transferred to another facility and /or for emergency care purposes. My healthcare provider may also share information with referring physicians for continuing care as deemed appropriate by me. Confidentiality will be waived if there is reason to believe a minor, elder or dependent adult is/has been at risk of abuse and/or if you are going to harm yourself or others. This consent is subject to revocation at any time in writing by me, except to the extent action has been taken in reliance on it.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: I acknowledge receipt of the VCC Notice of Privacy Practices which has been provided to me, upon becoming a patient at VCC. I understand that I have the right to request that VCC restrict my protected health information is used and disclosed for treatment, payment, and health care operations. I further understand that VCC is not required to agree to my requested restrictions; however, if VCC agrees to a requested restriction, it is bound by it.
CONSENT FOR TREATMENT: I voluntarily give my permission to the health care providers of VCC to provide services to me. I understand that by signing this form, I am authorizing them to treat me for as long as I seek care from VCC, or until I withdraw my consent in writing.
DENTAL: If I am receiving dental services, I acknowledge that I have received the Dental Materials Facts Sheet.
EMAIL AND TEXT CONSENT: Patients may be contacted via email and/or text messaging to remind me of an appointment, to obtain feedback on my experience with VCC’s healthcare team, VCC’s services offered, and to provide general health reminders/information. If at any time I provide an email or phone number at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email or phone number from VCC. I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. VCC does not charge for this service, but standard text messaging rates may apply.
San Diego Health Connect Opt-Out: Your health information will be contributed to the San Diego Health Connect database, unless you choose not to participate or to “opt-out”. If you choose to opt-out, physicians will not be able to look for your records in San Diego Health Connect, or have the most recent information about you, which may adversely affect your care. If you do not want to participate in San Diego Health Connect, you must complete, sign and submit the Opt-Out Form. By completing the Opt-Out Form, you are only opting out of San Diego Health Connect. Your records can still be shared directly between your health care providers outside of San Diego Health Connect using traditional methods (fax, mail, phone). If you choose to opt-out of San Diego Health Connect's health information exchange, we will still continue to provide you with health care treatment in our VCC facilities. You will not lose medical care because you have opted-out. A request to opt out of San Diego Health Connect's health information exchange will be effective approximately five (5) business days after you have submitted the Opt-Out form. The opt-out will not apply to any health information sent through San Diego Health Connect's health information exchange or exchanged with other participants in the health information exchange network before that date. You are free to opt back in at any time by completing an Opt-In Form that can be obtained from VCC's medical records department. A separate form must be completed by each family member wishing to opt-out.
This entire authorization is valid for all episodes of care rendered by all and any providers associated with VCC. I permit a copy of this authorization and agreement to be used in place of the original.