Consent to Patient Financial Responsibility
We appreciate the confidence you have shown in choosing "Pilaris", a service of Sukhdeo Medical, PLLC to provide your healthcare needs. The medical service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees.
You are responsible for payment of any costs charged by Sukhdeo Medical, PLLC. We expect these payments at the time of service. Since we do not participate in insurance plans, the entire cost of the visit and any laboratory tests are your responsibility. Submission of claims to your insurance company are your responsibility. In signing below, you hereby give permission to Sukhdeo Medical, PLLC to release any information concerning your treatment to insurance companies only if you have elected to have Sukhdeo Medical, PLLC file a claim on your behalf.
In signing below, you acknowledge that you have read the above policy regarding your financial responsibility to Sukhdeo Medical, PLLC for providing services to you. You certify that the information is to the best of your knowledge, true and accurate. You authorize any payment to Sukhdeo Medical, PLLC or the physician indicated, the full and entire amount of the bill incurred by you or the above named patient.
Consent to Contact
I hereby consent to "Pilaris" (Sukhdeo Medical, PLLC) with regard to calling my home, cell phone, business phone or other designated means of communication and leaving a message on my voicemail or in-person in reference to anything that assists in carrying out treatment, payment, and healthcare operations, including but not limited to appointment reminders, and any call pertaining to clinical care, including laboratory results, medications, and other information relating to treatment.
I hereby consent to Sukhdeo Medical, PLLC with regard to mailing me materials to my home or other designated address, text messaging or e-mailing me regarding anything pertaining to my clinical care, including PHI and other matters related to treatment, such as appointment reminders and patient statements, or payment for services. I acknowledge that Sukhdeo Medical, PLLC cannot and does not guarantee the privacy, security, or confidentiality of an e-mail message or text message sent or received.
Consent to Treatment
I hereby request and consent to diagnostic and medical treatment by "Pilaris" (operating as Sukhdeo Medical, PLLC), as deemed necessary in the professional medical judgement of my treating physician. I am aware the practice of medicine and related procedures is not an exact science and I acknowledge that no guarantees as to the outcome of any procedures, treatments or examinations have been made to me during my course of care. Furthermore, I give consent to Sukhdeo Medical, PLLC to take photographs or other images of me as they relate to my care, which made be used for purposes of documenting my medical status, for my medical benefit and for the purpose of medical education and training.
For female patients: Many oral and topical medications prescribed by dermatologists are unsafe for use during pregnancy. Please inform our office if you are pregnant, breastfeeding, or planning to become pregnant at any time while under the care of Sukhdeo Medical, PLLC.
General Release & Acknowledgement of Receipt of Notice of Privacy Practices
I, acknowledge and agree that I have had the right to review a copy of the Sukhdeo Medical, PLLC Notice of Privacy Practices prior to signing this consent, which provided me a more complete description of potential uses and disclosures of my protected health information (PHI). I hereby consent to Sukhdeo Medical, PLLC physicians, outside providers who are involved in my care, to obtain payment. I am aware that Sukhdeo Medical, PLLC disclaims any liability or harm resulting from my incorrect or incomplete provision of my primary care physician's contact information, and that Sukhdeo Medical, PLLC reserves the right to revise its Notice of Privacy Practices at any time. I am also aware that an updated copy of Sukhdeo Medical’s Notice of Privacy Practices is available on the Pilaris website.
Consent to Telehealth
By typing my name and signing this form, I understand and agree that I am signing this Consent electronically and that (i) I have reviewed, understand and accept the risks and benefits of telehealth services as described below and wish to receive such services, and (ii) I agree to the remaining terms of this Consent, including the terms described below.
If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.
By becoming a patient of Sukhdeo Medical, PLLC ("Pilaris"), I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my Pilaris provider and I will be able to see and speak with each other from remote locations.
I understand and agree that:I will not be in the same location or room as my medical provider.
My Pilaris provider is licensed in the state in which I am receiving services. I will report my location accurately during registration.
Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to the Pilaris office; (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.
Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment; (ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold Pilaris responsible for lost information due to technological failures.
I further understand that my Pilaris Provider’s advice, recommendations, and/or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that my Pilaris provider relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.
I may discuss these risks and benefits with my Pilaris provider and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to future treatment by Pilaris
I understand that the level of care provided by my Pilaris provider is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest Pilaris office, hospital emergency department or other appropriate health care provider.
I have the right to receive face-to-face medical services at any time by traveling to a Pilaris office that is convenient to me.
In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
I consent to, understand and agree that:I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.
Pilaris will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.
Before prescribing any controlled substance to me, Pilaris may review information from the Prescription Drug Monitoring Program in my state of residence regarding my prior receipt of controlled substances.
My Pilaris provider will not prescribe opioids, Schedule 2 controlled substances (including stimulant medications used to treat attention deficit disorders), or new prescriptions for benzodiazepines to me during a telehealth visit.
I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to Pilaris' standard policies regarding request and receipt of medical records and applicable law.
The laws of the state in which I am located will apply to my receipt of telehealth services.