Informed Consent
Largo Clinic is a "point of contact" practice. Our focus is on your acute medical or surgical problem at the time you present to this office. It is our intent to provide you with the best medical care possible within the scope of our experience and the physical facilities available in this office.
A medical membership at Largo Clinic is prepaid medical, not surgical care with us and does not represent insurance of any kind or access to any specialist or ancillary services.
Frequently medical diagnosis or surgical procedures require ancillary modalities such as laboratory tests or x-rays to provide you with appropriate care and treatment. Both x-rays and lab testing are available to this practice but are performed outside this facility. Any charges for those tests are your direct and immediate responsibility. Tests typically require a minimum 48 hour turnaround time before they are made available to our office. Based on our experience it is often appropriate to initiate treatment before performing blood tests or x rays. If such tests are ordered and you chose not to follow up in the office or obtain requested studies or testing, our ability to assist you with your health care needs may be severely limited. If your decision not to pursue testing is based on financial issues, please be aware that local hospital emergency departments will see you without any financial caveats.
Medicare Non-Provider Status
Dr George Kamajian has opted out of Medicare as of 2007. This office will continue to see all patients who present for treatment regardless of their insurance status. You, the patient, agrees to accept full responsibility for payment of our office charges. You understand that Medicare limiting charges do not apply to our office fees. You understand that neither you nor this office should submit a claim to Medicare. You understand that Medicare payments will not be made for items or services that otherwise would to have been covered by Medicare if no private contract existed. You understand you have the right to obtain Medicare covered items and services from participating Medicare physicians.
This practice is not open on nights or weekends or every day of the business week and we do not admit or see patients in the hospital. We will try to return calls promptly during office hours. This is a solo practice and there is no physician coverage for emergencies when this office is closed, and we do not always respond to after hour phone calls. Please proceed to the nearest emergency department or call 911 after our regular office hours.
Authorization and Agreement for Treatment
Consent to treatment: I hereby grant my authorization and consent to such treatment and procedures, including but not limited to trigger point injections, and certify that no guarantee or assurance has been made to me by Dr Kamajian or his staff as to the results or success obtained.
Complications: I understand that it is my responsibility to return to the Clinic or report any change in my condition to the clinic. If the clinic or Dr Kamajian is not available, I understand I must precede to the nearest emergency department or hospital.
Privacy notice: I acknowledge that I have received and/or read the HIPAA privacy notice. The undersigned certifies that he/she has read the above and is the patient, guarantor or the patient's representative duly authorized to execute this agreement and accept its terms.
By signing below you acknowledge that you have read the information above and agree to treatment under these guidelines.