Consent For Treatment/

Use of proctected health information/

financial obligation

Updated April 1, 2019

I hereby consent to medical evaluations, testing, and/or treatment provided by the staff of Coastal Mobile Medical Group, PLLC to provide all medical services to me.

 

I understand EnRoute Health, LLC provides the platform to communicate with the treating practitioners and Enroute Health, LLC does not provide any direct medical services.

I understand I will be treated by physician assistants and nurse practitioners who are licensed to practice medicine under the license of a physician. The PA and NP will have access to their supervising physician during the time of my visit. 

I understand that prior to treatments, procedures or receiving medications and vaccines I will be informed of the benefits, risk and possible side effects and allowed to ask questions for full knowledge to give informed consent.

 

I understand that it is my responsibility to provide any information relevant to health history, possible medication interactions and allergies.

 

I authorize Coastal Mobile Medical Group to obtain and utilize my medication history from other health care providers or third party pharmacy benefit payers to e-prescribe my prescriptions.

 

I acknowledge that I have reviewed the company Payment Policy and have been given the opportunity to ask questions and to have concerns and written request addressed.

 

I understand that fees are due at the time of service and Coastal Mobile Medical Group does not participate in health insurance.

 

I understand that membership with EnRoute Health is not a form of health insurance.  

 

I understand that previous balances owed will be requested at time of registration and any outstanding balance will be billed with accrued interest.

 

I understand that Coastal Mobile Medical group does not contract with Medicaid or Medicare plans.

 

I understand that all fees are due at the time of service and prior to receiving discharge paperwork and/or prescriptions that complete the visit encounter.

 

I understand that if the provider has ordered additional laboratory test that I will be sent to a local laboratory for lab collection and testing.

 

I understand I will be responsible for the charges incurred for these services and will receive a separate bill from the laboratory.

 

I understand that there may be a portion of the cost of Durable Medical Equipment that is not covered by my insurance company and I will be responsible for the balance.

 

I understand that the provider may use telemedicine and video technologies, and photographs of my injury or wound, etc. for treatment, consultation or specialist referrals.

 

I understand that I may be referred to a health care provider for follow up care and that I will be given the freedom of choice in referral selection.

 

If I do not have an established health care provider and have no preference in selection, I understand that my PHI may be sent to an affiliated health care organization to follow up with me to help coordinate my care.

 

I understand that if I have insurance, my insurance may not cover the services for which I am being referred and that I should verify coverage with that provider prior to my visit.

 

I understand that the company may use or disclose my Protected Health Information (PHI) necessary to carry out treatment, payment, or healthcare operations or in other instances as permitted by HIPAA.

 

I understand that the contact information I provide such as my physical address, phone number and email may be used to provide me with information on health-related benefits and services that may be of interest to me, to provide me with marketing and fundraising material and to send me patient satisfaction surveys.

 

I acknowledge and agree to my survey feedback being used on an anonymous basis on the website or other public sites to identify comments that the public may view and objectively review.

 

I understand that I have the right to opt out or unsubscribe to any information, materials or survey that I may receive.

 

I acknowledge that I was provided access to the Notice of Privacy Practices and the Patient Rights and Responsibilities.

 

I have been allowed the opportunity to ask questions, to file a complaint to have my concerns addressed, to submit a special written request and to object to the release of my PHI to a specific person if I so choose.

Online Video Visits | Telemedicine | Home Visits
SAN ANTONIO
CORPUS CHRISTI
TEXAS ONLINE URGENT CARE
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