This form applies to all Bethesda Newtrition and Wellness Solution practice sites. This form must be completed by all new patients and then again, at least annually or when the patient’s insurance or medical status changes.

Consent to Evaluation and Treatment: I hereby consent to the evaluation, diagnosis and treatment by Bethesda Newtrition and Wellness Solutions providers as applicable by the scope of their practice. I understand that it is my right to accept or refuse any treatment offered me. I acknowledge and understand that no guarantee has been made to me as to the results that may be obtained from such treatment. I understand that I could be tested for HIV/AIDS, and have the right to opt out. I understand that my consent will be requested for HIV/AIDS and other testing in case of an unintended exposure of a healthcare worker.

Electronic Prescribing: I authorize SureScripts and Office Ally, an electronic prescribing network, to release my medication refill history to Bethesda Newtrition and Wellness Solutions for the purposes of continued treatment. 

My Personal Belongings: I understand that I am responsible for my personal belongings and valuables.

Release of Information: I authorize Bethesda Newtrition and Wellness Solutions to release healthcare information for purposes of treatment, payment, or healthcare operations. Healthcare information from or regarding prior encounter(s) at other BNWS practice locations may be made available to subsequent BNWS affiliated sites to coordinate care. Healthcare information may be released to any person or entity liable for payment on the patient’s behalf in order to verify coverage or payment questions, or for any other purpose related t benefit payment. Healthcare information may also be released to my employer’s designee when the services delivered are related to a claim under worker’s compensation.

If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. This information may include, without limitation, medical history and physical, laboratory reports, physician progress notes, nurse’s notes, and consultations.

Federal and state laws may permit this medical practice to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their contractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this practice may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions , psychiatric conditions, intellectual disability conditions, genetic information, chemical dependence conditions and/or infectious diseases including but not limited to, blood borne diseases, such as HIV/AIDS.

Disclosures to Family and Friends: I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others listed below:

Patient Representative may revoke or modify this specific authorization and that revocation or modification must be in writing.

Communication Consent and Telephone Consumer Protection Act: I agree that when I provide my landline or cell phone number(s) below, I am giving express consent for BNWS and its associates, assignees, successors, and agents, to contact me at these numbers, or at any number that is later acquired for me and to leave live or pre-recorded messages on voicemail or to text, regarding scheduling or scheduled appointments, my services, or my bill. For greater efficiency, calls or texts may be delivered by an auto-dialer. I realize that as a consequence of providing this consent I may receive future calls or text messages that deliver pre-recorded messages by or on behalf of BNWS. Charges from your carrier may apply. Providing a telephone or cell phone number is not a condition of receiving services.

You may be contacted via voicemail, text or e-mail to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health information. I consent to receiving healthcare communications at the phone number or e-mail address provided. This request to receive e-mails and text messages applies to future communications unless I request a change in writing.

 

IMPORTANT: FOR MEDICARE PATIENTS ONLY

If you enroll or are currently enrolled with a Home Health Care Agency and/or Hospice, our Therapy services will NOT be covered until you are discharged from the Home Health Care Agency and/or Hospice. If this happens, you will be responsible for the cost of the rendered services (up to $150.00 per visit