PATIENT CONSENT FOR TREATMENT AND FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I authorize medical treatment as deemed necessary and appropriate by the physicians of Quality Urgent Care and their employees participating in my care.

With my consent, Quality Urgent Care may use and disclose Protected Health Information (PHI), about me to carry out treatment, payment and healthcare operations. Please refer to the Quality Urgent Careâs Notice of Privacy Practices for a more complete description of such uses and disclosures.

With my consent, Quality Urgent Care may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out treatment, payment or healthcare operations, such as appointment reminder, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, Quality Urgent Care may relay any items that assist the practice in carrying out treatment, payment or healthcare operations such as appointment reminders, insurance items, statement reminders and any information pertaining to my clinical care, including laboratory results among others, to:

With my consent, I authorize Quality Urgent Care to release medical information regarding the care and treatment I have received from this office to the physicians I have listed on the reverse side of this form.

I have the right to request that Quality Urgent Care restrict how it uses or discloses my PHI to carry out treatment, payment or healthcare operations. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

I authorize payment of insurance benefits directly to Quality Urgent Care. I understand that I am fully responsible for any medical or surgical charge incurred in the course of my treatment, co-pay, deductible, all other charges determined to be patient responsibility or other type of unpaid service in excess of any hospitalization or health insurance that might be applicable.

I hereby authorize Quality Urgent Care to submit a claim to the insurance company on my behalf and/or release pertinent information to my health insurance companies required in the course of my examination or treatment. I understand that it is my responsibility to report any change in my condition and/or return to Quality Urgent Care.

I authorize Quality Urgent Care to down load my medication history from a pharmacy clearinghouse.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Quality Urgent Care has the right to decline to provide treatment to me.

I understand that if labs are needed to be performed, I will receive a separate bill from the outside lab for those services. I understand it is my responsibility to know what laboratory that is preferred.

By signing this form, I am consenting Quality Urgent Careâs use and disclosure of my personal health information to carry out treatment, payment and healthcare operations.

Patient OR Legal Guardian Signature

Date:

Printed Name of Patient OR Legal Guardian:

Relationship to the Patient: