I, hereby authorize MedWise LLC and its affiliates, its employees and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address, social security number, Member ID number) for the purpose of helping me to resolve claims and health benefit coverage issues.

I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws. I understand that I have a right to revoke this authorization by providing written notice to. However, this authorization may not be revoked if, it’s employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization.

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.

I have been advised of this practice’s Privacy Practices, Release of Billing Information policy, Assignment of Benefits policy, and grant the practice Medication History Authority.

If applicable, Legal Representatives sign below:
By signing this form, I represent that I am the legal representative of the Member identified above and will provide written proof (e.g., Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the Member’s behalf with respect to this authorization form.

General Consent To Treatment- My signature below affirms that I agree/consent to the performance of diagnostic and therapeutic procedures deemed necessary by patient’s provider(s). I acknowledge that there are no guarantees, expressed and/or implied, as to the results of any and all medical procedure(s) or treatment(s).

Telemedicine- If my visit is to be conducted by telemedicine, I understand that the encounter includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I acknowledge there are potential risks to this technology, including interruptions and technical difficulties which may interfere with my evaluation and treatment and that my health care provider or I can discontinue the encounter at any time.   I understand that in some instances my situation may warrant an evaluation by another provider or referral to an emergency department if it is felt that the videoconferencing is not adequate for the situation or in the event of technology or equipment failure.

Release Of Information- I authorize the provider(s) providing services on behalf of the patient to release all billing information (including information of substance abuse and HIV status, if applicable) to providers or institutions providing follow-up care, the Social Security Administration, Medicare, Medicaid (or their intermediaries), insurance companies, health maintenance organizations, employers, law enforcement, or person(s) acting on behalf of a preferred provider arrangement or third party names on this patient information form (or any their agents or representatives) when said information is requested for payment, worker’s compensation, utilization review, or coverage determination purposes. I understand this authorization remains in effect unless revoked by me in writing delivered to this MedWise office.

Surescripts- I authorize the provider(s) providing services on behalf of the patient to utilize Surescripts for Benefit Optimization, Medication History, and Electronic Prescribing. I understand this authorization remains in effect unless revoked by me in writing delivered to this MedWise office.

Contacting Patients- You expressly consent and agree that, in order to discuss or service you account(s) (the “Accounts”) or to collect amounts you may owe, MedWise, and its officers, agents, affiliates, employees, and any affiliated or associated service providers and any third-party debt collection agency associated therewith (collectively “We”) may contact you by telephone at any telephone number associated with the Accounts, including wireless telephone number, which could result in charges to you. You expressly consent and agree that We may also contact you by sending text messages, emails, using any e-mail address you provide to us, or by pre-recorded or artificial voice or voice messages, automatic dialing methods, systems, or devices, and pre-recorded or artificial voice prompts at any telephone number associated with the Accounts, including wireless or mobile telephone numbers, regardless of whether you incur charges as a result.

Assignment of Insurance- I authorize any insurance benefits to pay directly to the providers providing services to the patient, all benefits due and payable as a result of services rendered.

Acknowledgment of Responsibility To Pay For Services- I understand that the provider(s) will, as a courtesy, file claims with all insurance carrier. However, I acknowledge and agree, except as provided by law, and in consideration of the service provided, that I will pay any charges which for any reason are not paid by any third-party payer unless there is a specific written agreement between the provider and the patient and payer.

Medicare Patients- Medicare will pay only for the service(s) it determines to be “reasonable and necessary”. I understand and agree to be personally and fully responsible for payment of charges for provider recommended service(s) and/or procedure(s) of which Medicare may deny payment.

Patient Rights- The Patient, or his or her representative, hereby acknowledges acceptance of information, including a copy of the Notice of Privacy Practices/Patient’s Rights and Responsibilities, which includes general information concerning your rights/responsibilities.

Acknowledgement Of Notice Of Privacy Practices- A complete description of how my medical information will be used and disclosed by MedWise is in the Notice of Privacy Practices/Patient’s Rights and Responsibilities, which I read before signing this agreement. I hereby acknowledge that a copy of same is available to me upon request and also posted in the clinic site. I have received a copy of MedWise Notice of Privacy Practices/Patient’s Rights and Responsibilities and agree and accept. Any reason for refusal is hereby explained:

Please read and initial the following:

____ I understand that I will be required to present my insurance card and personal identification EACH time I come to MedWise. Please understand that MedWise acknowledges this inconvenience to you; however, due to the rise in identity theft and changes in insurance coverage and providers, we must have your current information.
____ I understand that I am responsible for any/all monies/charges due as a result of service(s) rendered by MedWise and its providers. Amounts estimated or known to be payable by me are due and payable at the time of check-in or out. Please understand that billing you is based on insurance claim processing; we cannot just send you a bill.
____ I understand that my insurance coverage for MedWise may differ from my provider’s office or an emergency room. I understand and agree that I am responsible for any charges or amounts due and not paid by my insurance.
____ I understand that MedWise files my insurance claim as a courtesy to me as a patient. Filing may be either electronic or by mail, based on the requirements of the insurance carrier.
____ I understand that MedWise will ask for and is required to have certain personal information such as name, address, social security number, date of birth and other for the patient, policy holder and/or guarantor. This information will be used to file insurance claims and secure payment(s) for services.
____I understand that I or my employer may have “opted out” of certain MedWise benefit/payment arrangements. I understand and agree that I am responsible for any balance or monies due on my account.
____I understand that certain dental procedures are not covered by my insurance. I understand and agree that I am responsible for non-covered charges relating to those procedures or services.
____I understand that if my insurance coverage requires a referral or authorization, I am fully responsible for that process. In the event that this process is not completed, and the claim denied, I understand and agree that I am responsible for any and all charges/balances that are outstanding and due.
____If laboratory tests must be sent to an outside source for further evaluation, I understand I will be responsible for charges from that facility.

CERTIFICATION- By my signature below, I certify that I have read each of the above statements and acknowledge that they are true and correct. I acknowledge that I have requested an explanation of any item I have concerns about, and that process has been completed to my satisfaction. I also certify that I am the patient or am duly authorized by the patient to sign this agreement and accept its terms.

I authorize the release of any medical information and payment of medical benefits to MedWise Urgent Care for services necessary to process this claim and any future claims. I agree to be responsible for any deductible, co-insurance, co-pay, or any other balance not paid by my insurance.

Please sign by typing your name and date of birth.