I, the undersigned, do hereby give my consent Baystate Health Urgent Care, LLC (also referred to herein as the “Urgent Care Facility”) to furnish medical care and treatment considered necessary and proper in diagnosing and/or treating my (or his/her, as applicable) physical condition. I acknowledge that no guarantee can be made or has been made as to the results of treatment or examinations at the Urgent Care Facility.

I. Patient Rights.
This medical facility and/or practice is dedicated to providing the highest quality medical care in a manner that respects your rights. Under the law your rights include the following:
(a) Upon request, to obtain from the facility the name and specialty, if any, of the physician or other person responsible for your care or the coordination of your care while at this facility;
(b) To confidentiality of all records and communications to the extent provided by law;
(c) To have all reasonable requests responded to promptly and adequately within the capacity of the facility;
(d) Upon request, to obtain an explanation as to the relationship, if any, of the facility to any other health care facility or educational institution insofar as said relationship relates to your care or treatment;
(e) To obtain from a person designated by the facility a copy of any rules or regulations of the facility which apply to your conduct as a patient or resident;
(f) Upon request to receive from a person designated by the facility any information which the facility has available relative to financial assistance and free health care;
(g) Upon request, to inspect your medical records and to receive a copy thereof, and the fee for said copy shall be determined according to applicable law, except that no fee shall be charged to any applicant, beneficiary or individual representing said applicant or beneficiary for furnishing a medical record if the record is requested for the purpose of supporting a claim or appeal under any provision of the Social Security Act or federal or state financial needs–based benefit program, and the facility shall furnish the medical record requested pursuant to a claim or appeal under any provision of the Social Security Act or any federal or state financial needs-based benefit program within 30 days of the request; provided, however, that any person for whom no fee shall be charged shall present reasonable documentation at the time of such records request that the purpose of said request is to support a claim or appeal under any provision of the Social Security Act or any federal or state financial needs-based benefit program.
(h) To refuse to be examined, observed, or treated by students or any other facility staff without jeopardizing access to psychiatric, psychological, or other medical care or attention;
(i) To refuse to serve as a research subject and to refuse any care or examination when the primary purpose is educational or informational rather than therapeutic:
(j) To privacy during medical treatment or other rendering of care within the capacity of the facility:
(k) To prompt life saving treatment in an emergency without discrimination on account of economic status or source of payment and without delaying treatment for purposes of prior discussion of the source of payment unless such delay can be imposed without material risk to your health, and this right shall also extend to those persons not already patients or residents of a facility if said facility has a certified emergency care unit:
(l) To informed consent to the extend provided by law:
(m)Upon request to receive a copy of an itemized bill or other statement of charges submitted to any third party by the facility for care of the patient, and to have a copy of said itemized bill or statement sent to the attending physician of the patient;
(n) If refused treatment because of economic status or the lack of a source of payment, to prompt and safe transfer to a facility which agrees to receive and treat such patient. Said facility refusing to treat such patient shall be responsible for: ascertaining that the patient may be safely transferred; contacting a facility willing to treat such patient; arranging the transportation; accompanying the patient with necessary and appropriate professional staff to assist in the safety and comfort to the transfer; assuring that the receiving facility assumes the necessary care promptly, and providing pertinent medical information about the patient’s condition; and maintaining records of the foregoing;
(o) Upon request, to obtain an explanation as to the relationship, if any, of the physician to any other health care facility or educational institutions insofar as said relationship relates to your care or treatment: and such explanation shall include said physician’s ownership or financial interest, if any, in the facility insofar as said ownership relates to the care or treatment of said patient or resident:
(p) The right to freedom of choice in the selection of a facility, or a physician or a health service mode, except in the case of emergency medical treatment or as otherwise provided for by contract; provided, however, that the position or facility, or health service mode is able to accommodate the patient exercising such right of choice; and
(q) Upon reasonable request, to receive from a person designated by the facility an itemized bill reflecting charges, and third party credits and to be allowed to examine an explanation of said bill regardless of the source of payment. This information shall also be made available to the patient’s attending physician.

In the event that you have any questions or concerns about the quality of care or service you are receiving, you are encouraged to speak with the providers directly involved with your care and treatment. If your concerns are not resolved to your satisfaction, or if you would like the help of someone not immediately involved with your care or treatment, please contact the Vice President of Safety and Quality during business hours 800-258-4674 or by email at vpsq@shields.com.

You may also contact:

In Massachusetts:
Massachusetts Board of Registration in Medicine
200 Harvard Mill Square, Suite 330
Wakefield, MA 01880
Tel: 781-876-8200

Massachusetts Department of Public Health
Division of Health Care Safety & Quality
67 Forest Street
Marlborough, MA 01752
617-753-8000
DPH.BHCSQ@massmail.state.ma.us

In New Hampshire:
NH Department of Health & Human Services
129 Pleasant Street
Concord, NH 03301
Telephone: (603) 271-9039
E-mail: DHHS.HFA-Certification@dhhs.nh.gov

In Maine:
Maine State Department of Health and Human Services, Division of Licensing and Certification
41 Anthony Avenue
11 State House Station
Augusta, ME 04333-0011
1-800-791-4080 or (207)287-9300 (voice)
Website: https://www.maine.gov/dhhs/dlc


II. Patient Responsibilities
In order for the facility to provide you with the best care and treatment possible, your responsibilities as a Patient include the following:
(a) To provide complete and accurate information regarding your identity, medical history, hospitalizations, medications, and other relevant information;
(b) To pay close attention to the care you are receiving and to let the person(s) involved in your care know if you have any problems or concerns;
(c) To be considerate and respectful of other patients and the facility’s staff.
(d) To cooperate with the facility to ensure that financial obligations related to your care are met.

Self Pay: If I elect to pay for all services rendered in full today. I understand that my insurance will NOT be billed by Baystate Health Urgent Care, LLC.

Insurance – Assignment of Benefits: In consideration for the services provided by the Urgent Care Facility, I hereby assign and transfer to Baystate Health Urgent Care, LLC any and all rights, which I have against insurance companies, governmental agencies, or third party payers, for payment of charges for services provided by the Urgent Care Facility to me or to one of my dependents. I understand that I am responsible for and will pay the portion of my bill not covered by insurance companies, governmental agencies or third party payers. In consideration of services to be provided, I agree to pay Baystate Health Urgent Care, LLC in accordance with its regular rates and terms.

By signing this consent form I acknowledge that a copy of the Notice of Privacy Practices of Baystate Health Urgent Care, LLC has been offered and/or provided to me.

I authorize Baystate Health Urgent Care, LLC.to release verbally, electronically and/or in writing confidential medical information obtained during the course of my examination and/or treatment to any person or entity including other medical providers, insurance companies, government payers, third party payers or an employer (if treatment is related to employment), and/or to other healthcare provider(s) for purposes of treatment, payment of charges, quality assurance and utilization review. I understand that should I choose not to release my medical records to a specific entity and/or person(s) I must specifically state so in writing for inclusion in my medical record.

I hereby authorize Baystate Health Urgent Care, LLC to access my pharmacy benefits data electronically through SureScripts, Inc.’s online system. This authorization will enable the Urgent Care Facility to: (i) determine the pharmacy benefits and drug co-pays for my applicable health plan, (ii) determine whether a prescribed medication is covered under my health plan, (iii) display therapeutic alternatives with preference rank (if available) within a drug class for medications, (iv) determine the parameter of any e prescribing allowed by my health plan, and (v) download a historic list of all medications prescribed for me by any provider.

This authorization may include disclosure of prescription information related to alcohol and drug abuse, mental health treatment, and/or confidential HIV related information by SureScripts, Inc. to BAYSTATE HEALTH URGENT CARE, LLC

I have the right to revoke this authorization at any time by writing to BAYSTATE HEALTH URGENT CARE, LLC. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

Signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

Information disclosed under this authorization might be re-disclosed by the recipient, and this re-disclosure may no longer be protected by state or federal law.

This authorization expires one year from the date of my signature below.

THIS AUTHORIZATION DOES NOT AUTHORIZE BAYSTATE HEALTH URGENT CARE, LLC TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THOSE PERMITTED UNDER APPLICABLE LAW.

1. I acknowledge that the information I have filled out is correct to the best of my knowledge

2. I have received and/or read and understand the Notice of Patient Rights and Notice of Privacy Practices of BAYSTATE HEALTH URGENT CARE LLC

3. I hereby assign my insurance benefits applicable to the treatment I receive to be paid directly to Baystate Health Urgent Care, LLC.

4. I authorize BAYSTATE HEALTH URGENT CARE LLC to release medical information required to process bills/claims for payment related to treatment received at the Urgent Care Facility.

5. I have read and understand the Financial Policy for BAYSTATE HEALTH URGENT CARE LLC

6. I authorize BAYSTATE HEALTH URGENT CARE LLC to obtain/have access to my medication history

7. I authorize my provider’s office to contact me by mobile phone

Terms:
Maximum Charge amount up to: $1,000
Effective Dates: One Year of Acknowledgement
I agree to allow Baystate Health Urgent Care, LLC to charge my Credit Card/Debit/FSA/HRA/HSA card presented for any amount not covered by insurance, for all services provided by Baystate Health Urgent Care, LLC to the patient(s) on or after the effective date and before the expiration date. I acknowledge that:

• My credit card will be charged upon review of the final explanation of benefits from each applicable insurance company for services provided while this agreement is in effect.
• Once a total of up to $1,000 has been charged to my credit card under this agreement, Baystate Health Urgent Care, LLC will bill me directly for any amounts not covered by insurance.
• My credit card will be stored by Elavon, Inc., a secure, encrypted credit card processor affiliated with U.S Bank that partners with Baystate Health Urgent Care, LLC to collect payments. Baystate Health Urgent Care, LLC does not store any credit card information directly.
• I will receive notice 5 days prior via email that I provide for the amount to be charged.
• I will receive receipts detailing the amount charged.
• I may cancel this agreement at any time by contacting Baystate Health Urgent Care, LLC; any unpaid amounts relating to services provided while this agreement is in effect that are not covered by insurance will then be billed to me directly.

Please sign by typing your name and date of birth.