I have read or had read to me, and fully understand these consents and acknowledgments.

I have had an opportunity to ask questions and had these questions addressed.

I understand that I may withdraw this consent in writing. My withdrawal will not be effective for actions already taken by Any Resurgia Health Solutions practitioner or independent contractor, or any actions that may be in progress.

• CONSENT TO RECEIVE MEDICAL TREATMENT FROM RESURGIA HEALTH SOLUTIONS.
• ACKNOWLEDGE RECEIPT OF RESURGIA’S NOTICE OF PRIVACY PRACTICES.
• AGREE TO RESURGIA’S OPIATE AND PAIN MANAGEMENT AGREEMENT, IF NECESSARY.
• PROVIDE CONSENT FOR RESURGIA TO USE AND RELEASE MEDICAL AND PROTECTED HEALTH INFORMATION.
• AGREE TO RESURGIA’S PRACTICE POLICIES, INCLUDING RESURGIA’S FINANCIAL AND CREDIT CARD POLICIES.
• ACKNOWLEDGE FINANCIAL RESPONSIBILITY FOR COVERED AND NON-COVERED SERVICES RESURGIA WILL PROVIDE.
• ASSIGN INSURANCE BENEFITS AND REQUESTING PAYMENTS BE MADE TO RESURGIA ON THEIR BEHALF.
• PROVIDE RESURGIA WITH PERMISSION TO CONTACT PATIENT USING EMAIL, TEXT MESSAGE, AND PHONE CALLS (LIVE, AUTOMATED & RECORDED).
• RELEASE RESURGIA FROM LIABILITY FOR LOSS, THEFT, OR DAMAGE TO PERSONAL EFFECTS DURING THE COURSE OF A HOUSE CALL VISIT.
• PROVIDE CONSENT TO CHRONIC CARE MANAGEMENT SERVICES BY RESURGIA (MEDICARE PATIENTS ONLY).
• PROVIDE CONSENT FOR RESURGIA TO REQUEST AND RECEIVE PATIENT’S MEDICAL INFORMATION.
• CONFIRM THAT I AM NOT CURRENTLY UNDER HOSPICE CARE, AND WILL NOTIFY RESURGIA IF I AM PLACED UNDER HOSPICE CARE.