For access to our consent information, please see below:
Consent to Treat:
I hereby give my permission for Whitney Medical Urgent Care to give me medical treatment. I allow the Practice to file for insurance benefits to pay for the care I recieve. I have the right to discuss the treatment plan with my provider about the purpose, potential risks and benefits of any test ordered for me. I understand that any labs ordered are important in determining a final diagnosis and help guide my treatment.
I understand that Whitney Medical may have to send my medical record information to my insurance company. I must pay my share of costs. I must pay for the cost of these services if my insurance does not pay or if I dont have insurance. If insured I may recieve a separate bill from the lab company. I have the right to refuse any procedure or treatment. I have the right to discuss all medical treatments with my provider.
Phone Contact and Consent Authorization
I acknowledge that Whitney Medical Urgent Care may bill my insurance company for services provided. I agree to pay for services that are not covered or charges covered but not paid in full including, but not limited to, any co-payment, co-insurance, and / or deductible, or charges not covered by my insurance. I understand that there is a fee for returned checks. I acknowledge that Whitney Medical may use the services of a third party business associate or affiliated entity as an extended busienss office for medical account billing servicing. On the date of service, if you opt to not use insurance, whether not available or by choice, then you will be charged according to the facilitie's cash pay rates. The visit, for that particular DOS, will not be able to later be filed with any insurance companies. Likewise, if after insurance processes, if there is a significant patient responsibility or any leftover balane that amount must be collected in full before he/she may be seena gain. You may not elect to not file insurance after they have processed. Moreover, please note that depending on the visit coding, there may be additional fees mailed. Please note, that if any checks bounce there will be a $20 fee associated. If the required payment is not available at the start of the visit, then it is at the staff's discretion to offer a promise to pay, credit card authorization. The form will be populated authorizing the staff to run the on file credit card for the required amount on a future date. To process Medicare as the carrier, the latest insurance cards are required. If the card is not present at the date of service, the patient has 10 calendar days to provide before he/she is billed at our self-pay rates.
Consent to Obtain Patient Medication History
Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions. It is very important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate. Some pharmacies do not make prescription history information available, and your medication history might not include drugs purchased without using your health insurance. Also, over‐the‐counter drugs, supplements, or herbal remedies that you take on your own may not be included. I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers.
Phone Contact and Consent Authorization
I with respect to any services provided or that are planned to be provided to myself or, as an authorized legal representative, for the below listed individual, fully consent to and authorize Whitney Medical Urgent Care and Family Health ("Healthcare Provider") or any of its automated systems to contact me via phone (including my cellular phone by way of phone call or text message) in relation to any services received from a Healthcare Provider or any services planned to be received from a Healthcare Provider (including any billing items or appointment reminders). I agree the Provider or an agent of the Provider or an independent Physicians office may contact me for the purpose of scheduling necessary follow-up visits recommended by the treating providers. I consent to recordings / images of me being taken for patient care, security purposes and / or the practice's health care operations puproses. I understand that these images will be securely stored and protected. I understand if at any time I provide an email address or cell phone number at which I may be contacted, I consent to recieving unsecure instructions and other healthcare communications at the information I have provided. These instructions may include, but not are not limited to: post procedure instructions, follow up instructions, educational information, appointment reminders, and perscription information. Note: you may opt out of these communications at any time. The practice / clinic does not charge for this service, but standard text messaging rates or cellular telephone minutes may apply as provided in your wireless plan. Please contact your carrier for pricing plans and details.