Patient Consent Form

I have carefully read and fully understand the information provided to me below with regards to informed consent, and have had all my questions answered.

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.

General Consent

Consent for Medical Treatment. I give consent to Dimer Health Medical Practice, P.C. and its staff, physicians and other practitioners (collectively, the “Practice”) to provide and perform such medical care, tests, procedures, and other services that are deemed necessary or beneficial by the Practice for my health and well-being, or the health and well-being of the patient for whom I am legally authorized to provide such consent.

Telehealth Consent

Dimer Health Medical Practice, P.C. (the “Practice”) offers telehealth, which is the use of electronic communications to enable the Practice providers to deliver services. Telehealth is the use of two-way, real-time interactive audio/video technology between two locations to provide and support health services. Telehealth services are conducted between you and a Practice clinician. You may be at any location that you choose (e.g., your home or other location deemed appropriate).

Consenting to telehealth Services:

I understand that the laws that protect privacy and the confidentiality of medical information also apply to care rendered using telehealth modalities.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth services at any time without affecting my right to future care or treatment. I understand that I will not be denied care if I have a preference for in-person services.
I understand that one risk of telehealth services is that the equipment or the mechanism that is used to transmit the messages may be faulty, in which case I might then be unable to receive services or the session may end prematurely due to technological failures.
I understand that when engaged in telehealth services, it is my responsibility to ensure the privacy of my immediate environment.
I understand that that no results can be guaranteed or assured.
I have read the information provided above and that all of my questions have been answered to my satisfaction.

Other Authorizations

Chronic Care Management (CCM). If deemed appropriate by practice provider, I consent to receive Chronic Care Management (CCM) services from Dimer Health Medical Practice, P.C. I understand that I can stop CCM services at any time. I understand that CCM services include 24/7 access to a member of my care team. I understand that CCM services include a comprehensive care plan. I understand that CCM services include oversight of my medication regimen.

Advanced Primary Care Management (APCM). If deemed appropriate by practice provider, I consent to receive Advanced Primary Care Management (APCM) services from Dimer Health Medical Practice, P.C., which includes comprehensive care coordination, proactive monitoring of my chronic conditions, and 24/7 access to my care team. I understand that only one provider can furnish APCM services per calendar month, I have the right to stop these services at any time, and cost sharing may apply.

Filming. I understand that photographs or other images of me may be recorded for the Practice’s treatment and quality assurance purposes. To the extent that such images identify me, I understand that they shall receive the same confidentiality protections as my other health information.

Acknowledgement of Privacy Policy. Click here to review the Privacy Policy in its entirety.

Acknowledgement of Notice of Privacy Practices. Click here to review the Notice of Privacy Practices in its entirety. I acknowledge I have had the opportunity to receive assistance in the understanding of exercising these rights.

Authorization for Release of Information. By signing, I authorize the Practice to release my health information: (a) to any requesting health care provider for my further diagnosis, care or treatment or for that provider’s payment or health care operation purposes; (b) to any person or entity which may be responsible for billing/collection of claims for medical services or products; (c) to any person or entity which is, or may be liable to the Practice or me for all or part of the Practice’s charges, including but not limited to, third party payors; (d) to any government agency or other organization responsible for oversight of the Practice or a third party payor; (e) for the

Practice’s normal health care operations.

I grant permission and consent to the Practice to (a) leave voicemail messages for me, including information regarding amounts owed by me; (b) send me text messages using any wireless telephone numbers I provide; and (c) use pre-recorded/artificial voice messages and/or automatic dialing device in connection with any communications made to me. I understand such calls or contacts could result in charges to me depending on my wireless telephone service plan. The Practice will not be liable for any such charges associated with contacting me as set for above.

Financial Responsibility

Authorization of Payment of Insurance Benefits. I authorize payment to the Practice of all monies and/or benefits to which I may be entitled from government agencies, insurance carriers or others who are financially liable for my medical care and treatment to cover the costs of care and treatment. I hereby authorize the release of any/all medical records about me for the purposes of payment of the service rendered to me.

Signature on File (For Medicare patients). I certify that the information given to me in applying for payment under Medicare is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and/or Center for Medicare and Medicaid Services, or its intermediaries or carriers, any information needed for this or a related Medicare claim. I request that the payment or authorized benefits be made to me or on my behalf to the Practice for services provided by the Practice.

Financial Agreement. I agree to pay all amounts for which I am financially responsible, in accordance with the rates and terms of the Practice. I understand that, to the extent permitted by law, where insurance or other third-party benefits are insufficient, I will be responsible for the payment of any deductibles, copayments, coinsurance or other fees required by insurer or other benefit plan. I understand that if I have not provided the Practice with accurate and current information regarding my insurer or other benefit plan/third party payor which provides me with health care coverage, I will be personally responsible for the cost of all care rendered by the Practice. I understand that there will be a charge for all returned checks.

HIPAA Privacy and Release of Information Authorization

I hereby authorize Dimer Health 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.

In addition to the above, I hereby give authorization for protected health information to be shared with the following individual(s) or organization(s) noted in the HIPAA Release of Information Authorization Form.