CONSENT

I am voluntarily seeking medical care and/or treatment and consent the Village Clinic to provide medical care to me. I give permission to the medical staff of the Village Clinic to examine me, make diagnosis, and provide treatment to me in accordance with the information, explanations and recommendations they provide me.  
I give permission to the Village Clinic to bill my insurance for the care provided. If I do not have medical insurance, I understand that I am responsible for all charges incurred and that I will plan to pay or be billed for any outstanding balances in accordance with the Village Clinic billing policy. If my insurance is accepted, I authorize payment of benefits to the Village Clinic and its agents. I hereby authorize the Village Clinic to furnish information concerning my illness and treatment to my insurance carrier(s) in accordance with its privacy policy. I am advised that any tests (blood, urine, culture or other specimens) sent to an outside lab will result in additional changes which will be billed to my insurance carrier, and/or be billed directly to me by the laboratory. I understand that my insurance may not cover all charges deemed medically necessary by the Village Clinic. I also understand that I am responsible for any part of the charges that are not covered by my insurance and I will be billed directly for those services.  
I give my consent for the Village Clinic 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 Village Clinic describes such uses and disclosures more completely.
I have a right to review the notice of Privacy Practices prior to signing this consent. The Village Clinic 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 Village Clinic. 
With this consent, the Village Clinic 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 Village Clinic may decline to provide treatment to me.