Patient Consent Form

PART 2 - Patient Consent Form v3.0

Please Review & Act on These Documents

Please fill-out and sign our digital consent form, along w/ attaching pictures of your insurance cards by uploading them into this form, if available. After your digital signature is signed to this consent form our office staff will contact you or your loved one's caregiver to setup for a first visit.

We should already have your Patient Intake form.

IF not, please finish filling out this form first, and then click on the Patient Intake link after you submit this form



Consent

Patient Information

Title ( Mr., Mrs., etc. ) *
  • - select your title -
  • Mr.
  • Miss.
  • Mrs.
  • Dr.
  • Prof.
Please Choose One
Patients Full Name *
Field is required!
Patient's Date of birth * (mm/dd/yyyy)
Please Choose a Date
Patient's Primary Phone *
Enter Primary Phone ( xxx-xxx-xxxx )
Patient's Secondary Phone
Enter Phone Number ( xxx-xxx-xxxx )
Patients Email address
Invalid email address!
Patients Full Address *
Field is required!
Assisted Living or Independent Living Facility Info
Field is required!
Assisted Living Phone Number ( IF Necessary ) :
Field is required!

PART 2 - Patient Consent Form

Consent

Insurance Information

Primary Insurance Information :

  • - select your title -
  • Medicare
  • BCBS HMO / Advantage
  • McLaren Medicare
  • Meridian Medicare
  • Wellcare Medicare
  • Priority HMO / Advantage
  • Humana HMO / Advantage
  • BCN Advantage
Field is required!
Member ID *
Field is required!
Group Number
Field is required!
Plan Number
Field is required!
Upload image of your insurance card *
Upload image - 3MB Max
Field is required!
Click the " + " icon to attach a second image

Secondary Insurance Information :

NOTE : If there is NO 2nd insurance, choose "not applicable"
  • - select your title -
  • Not Applicable
  • Medicaid
  • BCBS PPO
  • Humana PPO
  • Priority Health PPO
  • VA Patient
  • Other
Field is required!
Member ID
Field is required!
Group Number
Field is required!
Plan Number
Field is required!
Upload image of your insurance card
Upload image - 3MB Max
Field is required!
Click the " + " icon to attach a second image

PART 2 - Patient Consent Form

Consent

Emergency Contact / Healthcare Advocate Information

Full Name *
Field is required!
Emergency Advocate Relationship *
Field is required!
Email Address *
Field is required!
Advocate Primary Phone *
Enter Phone Number ( xxx-xxx-xxxx )
Advocate Secondary Number
Enter Phone Number ( xxx-xxx-xxxx )

History or Additional Notes

Any Medical History ? - (ie. HTN, CHF, COPD, Dementia)
Field is required!
Any Surgical History ?
Field is required!
Any Allergies ?
Field is required!
Other Needs or Notes
Field is required!

Services Requested *

Field is required!

PART 2 - Patient Consent Form

Consent

GENERAL CONSENT FOR TREATMENT


Patient Authorization for the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operation



1. Consent To HomeMD Housecall Services Housecall Services

I request and authorize medical care as my physician, his assistant or designees (collectively called “the physicians”) may deem necessary or advisable. This care may include, but is not limited to, routine diagnostics, radiology and laboratory procedures, administration of routine drugs, biological and other therapeutics, and routine medical and nursing care.

I authorize my physician(s) to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I understand that my (the patient) care is directed by my physician(s) and that other personnel render care and services to me (the patient) according to the physician(s) instructions.

● I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees or promises have been made to me with respect to results of such diagnostic procedure or treatment.

● I understand that samples of body fluids and/or tissues may be withdrawn from me (the patient) during routine diagnostic procedures. I authorize HomeMD Housecall Services to dispose of the bodily fluids.

● I have been informed and understand that an HIV (human immunodeficiency virus – AIDS) test may be performed on me without my consent if a health professional or HomeMD Housecall Services employee or First Responder sustains an exposure to my blood or other body fluid.

● A drug screen by blood or urine sample may be obtained with verbal consent for purposes of verifying compliance with medication regimens or when abuse or misuse is suspected or when signs or symptoms of toxicity exist.

● I have been informed that registered nurses will be utilized to provide care coordination and monthly telephonic case management services to educate, inform and develop yearly care planning in an effort to maintain, improve and/or assist with transitional care management.



2. ACKNOWLEDGEMENT OF PRIVACY PRACTICES

The HomeMD Housecall Services Notice of Privacy Practices provides information about how protected health information about me (the patient) – including information about human immunodeficiency virus (HIV), AIDS-related complex (ATC) and acquired immunodeficiency (AIDS); including substance abuse treatment records protected under the regulation 42 Part 2, in the Code of Federal Regulations (if any); and psychological and social services records, including communication made to me to a social worker or psychologist (if any) may be disclosed. I have been offered an opportunity to review the Notice before signing this consent. I understand that the terms of the Notice may change, and I may obtain a revised copy by contacting the HomeMD Housecall Services office.

● I understand that I have the right to request restrictions on how my protected health information is used or disclosed for treatment, payment or healthcare operations. My providers from HomeMD Housecall Services are not required to agree to this restriction, but if they agree, will be bound by the agreement. I acknowledge that I have been offered and/or received the HomeMD Housecall Services notice of privacy practices.




PART 2 - Patient Consent Form

Consent

GENERAL CONSENT FOR TREATMENT ( CONTINUED ...)


Patient Authorization for the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operation



3. AUTHORIZATION TO RELEASE HEALTH INFORMATION

I understand that as part of my healthcare, HomeMD Housecall Services, originates, maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that my medication history and formulary benefits may be downloaded from a secure electronic clearinghouse. I understand that this information serves as:

● A basis for planning my care and treatment
● A means of communication among the many health professionals who contribute to my care
● A source of information for applying my diagnosis and surgical information to my bill
● A means by which a third-party payer can verify that services billed were provided
● A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I acknowledge that a copy of Notice of Privacy Practices was provided to me. I understand that I have the
following rights and privileges:

● The right to review the notice prior to signing this consent
● The right to object to the use of my health information for directory purposes
● The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations.

I understand that HomeMD Housecall Services is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that HomeMD Housecall Services reserves the right to change its notice and practices, in accordance with Section 164.520 of the Code of Federal Regulation. Should HomeMD Housecall Services change its notice, it will send a copy of any revised notice to the address I have provided (whether U.S. mail or, if I agree, via email).



4. ASSIGNMENT OF INSURANCE BENEFITS / HEALTH RECORDS RELEASE
Medicare Certification: I certify that the information provided by me in applying for payment under TITLE XVII of the Social Security Act is correct and request on my behalf all authorized benefits.

I hereby authorize and instruct my insurance carrier to make payment directly to HomeMD Housecall Services for benefits (payments) otherwise payable to me. I agree to personally pay for any charges that are not covered by or collected from any insurance program, including any deductibles and coinsurance amounts.




PART 2 - Patient Consent Form

Consent

Your Consent

I HAVE READ OR HAD READ TO ME AND FULLY UNDERSTAND THIS CONSENT ; I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND HAD THESE QUESTIONS ADDRESSED.


Signed by (patient or responsible party):



Choose One
Patients Name *
Please type in your name
Patient Signature * - ( Please sign here )
Please sign here
Name of Caregiver authorized to sign on behalf of patient *
Please type in your name
Responsible Caregiver’s signature * - ( Please sign here )
Please sign here


CONSENT TO THE RELEASE OF MEDICAL INFORMATION:



I authorized the release of health information from other medical entities to be transferred to HomeMD Housecall Services to expedite their provision of quality care on my behalf/the behalf of my loved one. This includes but is not limited to; inpatient hospital and rehab reports and discharge paperwork, skilled care and hospice paperwork/records, diagnostic reports, and documents pertaining to any and all outpatient medical services.


I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I understand and acknowledged that I received a Notice of Privacy Practices, and I consent to such disclosures as delineated in the Notice. I understand that this may include information relating to; acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), behavioral health service/psychiatric care, and treatment for alcohol and/or drug abuse.



Select an Expiration Date for Records Request ( up to 2 years )
Select an expiration date for Requesting Records


Signed by(patient or responsible party):


Patient Name *
Field is required!
Patient Signature * - ( Please sign here )
Field is required!
Name of caregiver authorized to sign on behalf of patient *
Field is required!
Responsible Caregiver Signature * - ( Please sign here )
Field is required!
Confirm you read and understand privacy policy.
Confirm you read and understand the Electronic Record and Signature Disclosure

Do NOT follow this link or you will be banned from the site!
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