Platte County Health Department has offered me a copy of their "Notices of Privacy Practices"
I hereby grant permission to the Platte County Health Department to obtain laboratory speciments or perform minor procedures ordered by the provider or by the nursing staff operating under standing orders. I also understand it is my responsibility to contact Platte County Health Department for all test results if I have not received results within two weeks. All positive STD results will be reported to the Missouri Department of Health and if HIV positive or TB positive, I will be offered management services. NO prescriptions (refills or new) will be called in after business hours.
I hereby authorize The Platte County Health Department to use telemedicine in the course of my diagonosis and treatment.
Please indicate where we CAN call/leave a message with you:Home: Home Phone Number* Cell: Cell Phone Number* Work: Work Phone Number* Other: Other Phone Number* Enter 0000 for those that are blank
Please list to whom your medical records may be released to:Name: Full Name Date: Date Name: Full Name Date: Date
Notice to Clients
Funding for the Family Healthcare Clinic is provided by the city of Kansas City, Northland Healthcare Access, and the Platte County Health Department
I agree to pay for services and/or supplies incurred at the rate indicated on the Family Healthcare Fee Schedule. Failure to comply with this agreement may jeopardize my ability to continue receiving services at the Platte County Health Department-Family Healthcare Clinic.
Cancellation of an Appointment
In order to be respectful of the medical needs of other patients, please be courteous and call the clinic promptly if you are unable to shopw up for an appointment. We ask that you call at least 24 hours in advance.
Patients who schedule and then do not keep 3 appointments, within a year, may jeopardize your ability to be seen in a timely manner. Patient will be counseleed upon 3rd No-Show with future appointment options.
I have read and understand the above agreement.