Consent To Treatment
The undersigned consents to performance of medical services. This may include medical evaluation, procedures and treatment. Such procedures may include, but are not limited to: IV placement, X-rays, wound repair, blood draw and
incision and drainage of abscesses. Treatment modalities include oral, intravenous, intramuscular, subcutaneous and
inhaled medications, fracture treatment including splints and slings, wound repair including bio- occlusive glue and
sutures. I understand that medical care is not an exact science and that no guarantee or warrantee is being made as to
my examination, treatment, result or outcome. We are not an Emergency Room and are unable to provide medical
services for life-threatening and/or serious illnesses. If you believe you have a life-threatening and/or serious illness,
please call 911 or go directly to an Emergency Room. I understand that I am free to withdraw my consent and to
discontinue participation in these procedures at any time. However, I understand that doing so may hinder my
treatment and/or medical outcome. All practitioners (physicians, physician assistants, nurse practitioners) furnishing
services to the undersigned are fully licensed practitioners.
CONSENT TO ACQUIRE, USE AND DISCLOSE INFORMATION
I agree and consent to the acquisition, use and disclosure of past and current medical records related to my health
information for the purpose of care navigation, treatment, payment from third party payers, and other healthcare
operations, such as the maintenance of medical records, communication of health information with other health
professionals who contribute to my care, and quality peer reviews and assessments.
PRIVACY NOTICE ACKNOWLEDGEMENT
I have received a copy of the Notice of Privacy Practices as required by the Health Insurance Portability and Accountability Act.
ACCIDENTAL BODILY FLUID EXPOSURE TO HEALTHCARE WORKER
In the case of my bodily fluid exposure to a healthcare employee, I consent to testing, which may include, but not
limited to, HIV or Hepatitis, to determine the presence of any communicable disease for the benefit of the exposed
employee. I understand that these test results do not become a part of my medical record.
CONSENT TO PHOTOGRAPH
I grant permission for my Healthcarelive Medical Group, Inc. or it’s subscribers to take photographs, should the need
arise, for purpose of my treatment during my health evaluation and treatment.
CONSENT TO TEXT
I grant permission for my treating Healthcarelive Medical Group, Inc. or it’s subscribers to send me text messages
regarding wait times, my appointments, follow up questions, billing questions and attempts to collect payment the
need arise.
PERSONAL VALUABLES
Although the facility will make all reasonable efforts in safeguarding my valuables, I understand that my treating
medical group is not responsible for the loss or damage of personal valuables.
ASSIGNMENT OF INSURANCE BENEFITS!
I assign the medical group all rights, title, and interest in any and all health insurance, including Medicare and/or
health plan proceeds/benefits from any plan(s) arising from the provision of any goods and services provided by the
medical group and/or physicians/healthcare providers thereof. At my medical group’s election, I also assign 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 Healthcarelive Medical Group,
Inc and its subscribers, and agree to immediately remit all payments received from insurance for those services. I
agree to cooperate with Healthcarelive Medical Group or its subscribers in collecting any such benefits. This assignment
shall not obligate Healthcarelive Medical Group, Inc 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.
FINANCIAL RESPONSIBILITY
Agreed upon payment are due at time of service including copays or Prompt Pay fees. Fees are accepted by credit
card. 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. 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.
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 Consent to Evaluation and Treatment and to
accept its terms.