Conditions and Consent for Outpatient Care
In this document, “Patient” means the person receiving treatment. “Patient Representative” means any person acting on behalf of the Patient and signing as the
Patient’s representative. Use of the word “I”, “you”, “your” or “me” may in context include both the Patient and the Patient
Representative. With respect to financial obligations “I” or “me” may also, depending on the context, mean financial guarantor “Guarantor”.
“Provider” means the CLINICS and may include healthcare professionals on the CLINIC’s staff and/or CLINICS-based physicians, which include but are not limited to:
Emergency Department Physicians, Pathologists, Radiologists, Anesthesiologists, Clinician, certain other licensed independent practitioners and any authorized agents,
contractors, affiliates, successors or assignees acting on their behalf.
Legal Relationship between CLINICS and Physicians. Most or all of the physicians performing services in the CLINICS are independent and are not CLINICS agents or
employees. Independent physicians are responsible for their own actions and the CLINICS shall not be liable for the acts or
omissions of any such independent physicians.
1. Consent to Treatment. I consent to the procedures which may be performed during this CLINICS visit or during an outpatient episode of care, including, but not
limited to, emergency treatment or services, and which may include laboratory procedures, x-ray examination, diagnostic procedures, medical, nursing or surgical
treatment or procedures, anesthesia, or CLINICS services rendered as ordered by the Provider. I consent to allowing students as part of their training in health care
education to participate in the delivery of my medical care and treatment or be observers while I receive medical care and treatment at the CLINICS, and that these
students will be supervised by instructors and/or CLINICS staff. I further consent to the CLINICS conducting blood-borne infectious disease testing, including but not
limited to, testing for hepatitis, Acquired Immune Deficiency Syndrome (“AIDS”), and Human Immunodeficiency Virus (“HIV”), if a physician orders such tests or if
ordered by protocol. I understand that the potential side effects and complications of this testing are generally minor and are comparable to the routine collection of
blood specimens, including discomfort from the needle stick and/or slight burning, bleeding or soreness at the puncture site. The results of this test will become part of my confidential medical record.
2. Consent to Photographs, Videotapes and Audio Recordings. I consent to photographs, videotapes, digital or audio recordings, and/or images of me being
recorded for security purposes and/or the CLINICS’s quality improvement and/or risk management activities. I understand that the facility retains the ownership
rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used outside of the facility without a specific written authorization from me or my legal representative unless otherwise required by law.
3. Financial Agreement. In consideration of the services to be rendered to Patient, Patient or Guarantor individually promises to pay the Patient’s account at the rates
stated in the CLINICS’s price list (known as the “Charge Master”) effective on the date the charge is processed for the service provided, which rates are hereby expressly incorporated by reference as the price term of this agreement to pay the Patient’s account. Some special items will be priced separately if there is no price listed on the Charge Master. An estimate of the anticipated charges for services to be provided to the Patient is available upon request from the CLINICS. Estimates may vary significantly from the final charges based on a variety of factors, including, but not limited to, the course of treatment, the intensity of care, physician practices, and the necessity of providing additional goods and services. Professional services rendered by independent contractors are not part of the CLINICS bill (special cases category).
These services will be billed to the Patient separately. I understand that physicians or other health care professionals may be called upon to provide care or
services to me or on my behalf, but that I may not actually see, or be examined by, all physicians or health care professionals participating in my care; for example, I
may not see physicians providing radiology, pathology, EKG interpretation and anesthesiology services. I understand that, in most instances, there will be a separate
the charge for professional services rendered by physicians to me or on my behalf, and that I will receive a bill for these professional services that are separate from the bill for CLINICS services. The CLINICS will provide a medical screening examination as required to all Patients who are seeking medical services to determine if there is an emergency medical condition without regard to the Patient’s ability to pay. If there is an emergency medical condition, the CLINICS will provide stabilizing treatment within its capacity. However, the Patient and Guarantor understand that if the Patient does not qualify under the CLINICS’s charity care policy or other applicable policy, the Patient or Guarantor is not relieved of his/her obligation to pay for these services. If supplies and services are provided to a Patient who has coverage through a governmental program or through certain private health insurance plans, the CLINICS may accept a discounted payment for those supplies and services. In this event, any payment required from the Patient or Guarantor will be determined by the terms of the governmental program or private health insurance plan. If the Patient is uninsured and not covered by a governmental program, the Patient may be eligible to have his or her account discounted or forgiven under the CLINICS’s uninsured discount or charity care programs in effect at the time of treatment. I understand that I may request information about these programs from any healthcare service providers. I also understand that, as a courtesy to me, the CLINICS may bill an insurance company offering coverage, but may not be obligated to do so. Regardless, I agree that, except where prohibited by law, the financial responsibility for the services rendered belongs to me, the Patient or Guarantor. I agree to pay for services that are not covered and covered charges not paid in full by insurance coverage including, but not limited to, coinsurance, deductibles, non-covered benefits due to policy limits or policy exclusions, or failure to comply with insurance plan requirements. This clinic reserves the right not to submit a claim to a patient’s insurance company. Upon written request, the CLINICS will provide the information necessary for the patient to file the insurance claim, except as prohibited by law.
4. Third Party Collection. I acknowledge that the Providers may utilize the services of a third party Business Associate or affiliated entity as an extended business
office (“EBO Servicer”) for medical account billing and servicing. During the time that the medical account is being serviced by the EBO Servicer, the account shall not be considered delinquent, past due or in default, and shall not be reported to a credit bureau or subject to collection legal proceedings. When the EBO Servicer’s efforts to obtain payment have been exhausted due to a number of factors (for e.g., Patient or Guarantor’s failure to pay or make a payment arrangement after insurance adjustments and payments have been credited, and/or the insurer’s denial of claim(s) or benefits is received), the EBO Servicer will send a final notice letter which will include the date that the medical account may be returned from the EBO Servicer to the Provider. Upon return to the Provider by the EBO Servicer, the Provider may place the account back with the EBO Servicer, or, at the option of the Provider, may determine the account to be delinquent, past due and in default. Once the medical account is determined to be delinquent it may be subject to late fees, interest as stated, referral to a collection agency for collection as a delinquent account, credit bureau reporting and enforcement by legal proceedings. I also agree that if the Provider initiates collection efforts to recover amounts owed by me or my Guarantor, then, in addition to amounts incurred for the services rendered, Patient or Guarantor will pay, to the extent permitted by law: (a) any and all costs incurred by the Provider in pursuing collection, including, but not limited to, reasonable attorneys’ fees, and (b) any court costs or other costs of litigation incurred by the Provider.
5. Assignment of Benefits. Patient assigns all of his/her rights and benefits under existing policies of insurance providing coverage and payment for any and all
expenses incurred as a result of services and treatment rendered by the Provider and authorizes direct payment to the Provider of any insurance benefits otherwise
payable to or on behalf of Patient for outpatient services, including emergency services, if rendered. Patient understands that any payment received from these policies and/or plans will be applied to the amount that Patient or Guarantor has agreed to pay for services rendered during this admission and, that Provider will not retain benefits in excess of the amount owed to the Provider for the care and treatment rendered during the admission. I understand that any health insurance policies under
which I am covered may be in addition to other coverage or benefits or recovery to which I may be entitled, and that Provider, by initially accepting health insurance
coverage, does not waive its rights to collect or accept, as payment in full, any payment made under different coverage or benefits or any other sources of payment that
may or will cover expenses incurred for services and treatment. I hereby irrevocably appoint the Provider as my authorized representative to pursue any claims,
penalties, and administrative and/or legal remedies on my behalf for collection against any responsible payer, employer-sponsored medical benefit plans, third party
liability carrier or, any other responsible third party (“Responsible Party”) for any and all benefits due me for the payment of charges associated with my treatment.
This assignment shall not be construed as an obligation of the Providers to pursue any such right of recovery. I acknowledge and understand that I maintain my right of
recovery against my insurer or health benefit plan and the foregoing assignment does not divest me of such right. I agree to take all actions necessary to assist the
Provider in collecting payment from any such Responsible Party should the Provider(s) elect to collect such payment, including allowing the Provider(s) to bring suit
against the Responsible Party in my name. If I receive payment directly from any source for the medical charges associated with my treatment acknowledge that it is
my duty and responsibility to immediately pay any such payments to the Provider(s). I assign and transfer to (1) the CLINICS and to (2) authorized and attending
physicians of the CLINICS any and all benefits, monies, and sums payable to me for CLINICS visit, sickness, accident or bodily injury under any clinics visit, sickness, accident medical payments/PIP/bodily injury or uninsured/underinsured motorist policy providing for CLINICS, medical or physician payments.
6. Procedure Room. I understand and agree that I am (or Guarantor is) responsible for any additional charges associated with the request and/or use of a procedure
7. Outpatient care. I acknowledge that I am responsible for any drugs furnished to me while an outpatient that meet PUTRACARE’s definition of a prescription drug.
These drugs are also referred to as self-administered drugs, as they are usually self-administered but they may be administered to me by CLINICS personnel.
8. Communications About My Healthcare. I authorize my healthcare information to be disclosed for purposes of communicating results, findings, and care decisions
to my family members and others I designate to be responsible for my care. I will provide those individuals with a password or other verification means specified by
the CLINICS. I agree I may be contacted by the Provider or an agent of the Provider for the purposes of scheduling necessary follow-up visits recommended by the
9. Consent to Telephone Calls for Financial Communications. I agree that, in order for you, or your EBO Servicers and collection agents, to service my account or to
collect any amounts I may owe, I expressly agree and consent that you or your EBO Servicer and collection agents may contact me by telephone at any telephone
number I have provided or you or your EBO Servicer and collection agents have obtained or, at any number forwarded or transferred from that number, regarding the
CLINICS visit, the services rendered, or my related financial obligations. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.
10. Consent to Email or Text Usage for Additional Instructions and Other Healthcare Communications.
If at any time I provide an email or text address at which I may be contacted, I consent to receive additional instructions and other healthcare communications at that
email or text address from the Providers. These additional instructions may include, but not be limited to: postoperative instructions, physician follow-up instructions,
dietary information, and prescription information. The other healthcare communications may include but are not limited to communications to family or designated
representatives regarding my treatment or condition, or reminder messages to me regarding appointments for medical care.
11. Release of Information. I hereby permit Providers to release healthcare information for purposes of treatment, payment or healthcare operations for case
management purposes. Healthcare information may be released to any person or entity liable for payment on the Patient’s behalf in order to verify coverage or
payment questions, or for any other purpose related to benefit payment. Healthcare information may also be released to my employer’s designee when the services
delivered are related to a claim under worker’s compensation. If I am covered by SOCSO/FWCS/SPIKPHA, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of the claim. This information may include, without limitation, history and physical, emergency records, laboratory reports, operative reports, physician progress notes, nurse’s notes, consultations, psychological and/or psychiatric reports, drug and alcohol treatment. Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIDS.
12. Other Acknowledgements.
Personal Valuables. PUTRACARE does not hold responsibility for any damage or loss of personal valuables within their premises.
Weapons/Explosives/Drugs. I understand and agree that if the CLINICS at any time believes there may be a weapon, explosive device, illegal substance or drug, or
any alcoholic beverage in my room or with my belongings, the CLINICS may search my room and my belongings located anywhere on CLINICS property, confiscate any
of the above items that are found, and dispose of them as appropriate, including the delivery of any item to law enforcement authorities.
Patient Visitation Rights. I understand that I have the right to receive the visitors whom I or my Patient Representative-designate, without regard to my relationship
with these visitors. I also have the right to withdraw or deny such consent at any time. I will not be denied visitation privileges on the basis of age, race, color, national
origin, religion, gender, gender identity and gender expression, and sexual orientation or disability. All visitors I designate will enjoy full and equal visitation privileges
that are no more restrictive than those that my immediate family members would enjoy. Further, I understand that the CLINICS may need to place clinically necessary
or reasonable restrictions or limitations on my visitors to protect my health and safety in addition to the health and safety of other Patients. The CLINICS will clearly
explain the reason for any restrictions or limitations if imposed. If I believe that my visitation rights have been violated, I or my representative has the right to utilize
the CLINICS complaint resolution system.
Additional Provision for Minors/ Incapacitated Patients. I, the undersigned, acknowledge and verify that I am the legal guardian or custodian of the minor/incapacitated patient.
13. Notice of Privacy Practices. I acknowledge that I have received the PROVIDER Notice of Privacy Practices, which describes the ways in which the CLINICS may use and disclose my healthcare information for its treatment, payment, healthcare operations and other prescribed and permitted uses and disclosures. I understand that this information may be disclosed electronically by the Provider and/or the Provider’s business associates. I understand that I may contact the CLINICS Privacy Officer designated on the notice if I have a question or complaint.
14. Acknowledgment: I have been given the opportunity to read and ask questions about the information contained in this form, specifically including but not
limited to the financial obligation’s provisions and assignment of benefits provisions, and I acknowledge that I either have no questions or that my questions have been answered to my satisfaction and that I have signed this document freely and without inducement other than the rendition of services by the Providers.
Date: I, the undersigned, as the Patient or Patient Representative, or, for a minor/incapacitated Patient, as the legal guardian, hereby certify I have read, and fully and completely understand this Conditions and Authorization for Medical treatment, and that I have signed this Conditions and Authorization for Medical Treatment
knowingly, freely, voluntarily and agree to be bound by its terms. I have received no promises, assurances, or guarantees from anyone as to the results that may be
obtained by any medical treatment or services. If insurance coverage is insufficient, denied altogether, or otherwise unavailable, the undersigned agrees to pay all
charges not paid by the insurer.
15. Acknowledgment of Notice of Patient Rights and Responsibilities. I have been furnished with a Statement of Patient Rights and Responsibilities ensuring that
I am treated with respect and dignity and without discrimination or distinction based on age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy,
sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis
prohibited by federal, state, or local law.