Consent to Treatment
The undersigned consents to the performance of medical services, administration of medications and, other medical procedures (“Services”) by (“Provider”) at CityHealth Urgent Care, as deemed appropriate by Provider’s medical personnel. I understand that medical care is not an exact science and no guarantees have been made regarding the outcome of treatment. I acknowledge that I have reviewed and agree with the Consent to Treatment.
Release of Information
I authorize Provider and any other holder of information about me to disclose all or any part of my medical record or other information needed to determine my eligibility for benefits or the amount of benefits payable for Services rendered by Provider, now or in the future, to any financially responsible party, including but not limited to: the Centers for Medicare and Medicaid (CMS), Medicaid,
their intermediaries or carriers, Worker’s Compensation carriers, health or liability insurers, or any other insurance organization or billing agent (collectively, “Insurer”). I authorize any holder of medical and billing information about me to release to Provider or any Insurer any information necessary for billing and payment purposes. I consent to the use of a copy of this authorization in lieu of
the original. I acknowledge that I have reviewed and agree with the Release of Information.
Assignment of Benefits
I request and authorize direct payment to Provider of any Medicare and other insurance benefits payable to me or on my behalf for Services rendered by Provider, now or in the future. At Provider’s election, I also assign to Provider all of my rights and interest in all such insurance benefits or proceeds, including but not limited to the right to appeal any denial of benefits or to file any lawfully authorized lien necessary to secure payment from any third party or a third party’s Insurer. I understand that I am financially responsible for the services rendered by Provider and agree to immediately remit all payments received from insurance for those services. I agree to cooperate with Provider or its agent in collecting any such benefits. This assignment shall not obligate Provider to file any appeal or perfect any such lien and nothing herein shall relieve me from direct financial responsibility for any charges not paid by an
Insurer. I acknowledge that I have reviewed and agree with the Assignment of Benefits.
Financial Responsibility
Payment in full is due at time of service. I acknowledge that many Insurers will only pay for services that they determine to be medically necessary and that meet other coverage requirements. For example, some Insurers require prior authorization for certain services. If my Insurer determines that the Services, or any part of them, are not medically necessary or fail to meet other coverage requirements, the Insurer may deny payment for that Service. Notwithstanding any other provision herein, I agree that if my Insurer denies all or any part of Provider’s charges for any reason, or if I have no insurance, I will be personally and fully responsible for payment of Provider’s charges. Should my account be referred to an attorney or collection agency, I agree to pay actual attorney’s fees and collection expenses. All delinquent accounts shall bear interest at twelve percent per annum, not to exceed the maximum amount permitted by law.
Credit Card Authorization Agreement/Consent
If you have provided your insurance information during your visit today, our billing team will send a claim to your insurance company shortly after your visit. Once the claim is processed, your insurance company will send us an Explanation of Benefits (EOB) with the amount you owe. If you have a remaining balance, we will charge the credit card you have left on file with us, for that remaining balance. If you have any questions regarding your balance, please notify our Billing Team at [email protected] or call 925-753-0198. By signing this form, you are consenting to leave a credit/debit/HSA or FSA card on file with CityHealth Urgent Care. Your information will be stored using the same encrypted, secure software used to store your medical records. You are also consenting to have your card charged for any remaining balances. I acknowledge that I have reviewed and agree with the Financial Responsibility.
Signature
The undersigned certifies that he/she has read the foregoing, and is the patient, the patient’s legal representative or is duly authorized by the patient as the patient’s agent to execute this Conditions of Service and Consent to Treat and to accept its terms.