Thank you for choosing Boca Mobile Health Services for your primary care needs. Our goal is to provide exemplary care in the place you call home. For us to provide these services, consents & financial responsibility must be obtained. Please read each section fully before initialing and signing the consent page. We look forward to knowing you.
GENERAL CONSENT FOR CARE AND TREATMENT
TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended medical or diagnostic procedure to be used so that you may make the decision whether to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended, however your primary care is our first priority. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate medically necessary treatment and/or procedure for any conditions we may identify through the course of care.
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended and (2) you consent to treatment at your home or any institution at which you maintain a residence, whether short or long-term. You have the right to discontinue services by our practice at any point.
You have the right to discuss the treatment plan with your healthcare provider including the purpose, potential benefits or risks, and long-term strategies involved in your care. If you have any questions regarding any treatment plan recommended by your provider, we encourage you to speak up.
I voluntarily request a physician as well as other health care
providers to provide reasonable and necessary medical examinations, testing, and/or treatment for the conditions for which I sought care. I understand that if additional testing or procedures are recommended, I will be asked to read and sign an additional consent form specific to that test or procedure.
MEDICAL RECORDS RELEASE REQUEST
As part of your care plan, we will need your authorization to obtain your medical records. This will help our team of clinical professionals have a comprehensive understanding of your medical history and needs. Please check the Medical Records Request box in the Consent To Treat section below for your approval.
CONSENT FOR FINANCIAL RESPONSIBILITY
Thank you for choosing Boca Mobile Health Services as your provider. Providing excellent care is what we are here for and in order to continue providing this service to our patients, financial responsibility must be established. The following policy must be read and agreed to prior to services.
Boca Mobile Health Services is able to provide medically necessary services to you by ensuring payment in a timely manner. In order to provide these services and ongoing support, we expect our patients to understand and abide by the established policies and procedures including this patient financial responsibility statement.
Annual membership with monthly home visit is the current package. We do not accept any insurance carriers at this time. Full payment for membership is requested prior to first medical visit. You may cancel at any time.
Although we do not accept insurance, you may be able to apply your insurance for any labs or imaging tests ordered. You are responsible for knowing and understanding the benefits provided to you by your insurance carrier. Knowing whether a lab test of imaging requires prior authorization, or even needs a referral will be solely your responsibility. Any denial for reasons such it is matter for patient to discuss with insurance company directly.
PRIVACY PRACTICE
Boca Mobile Health Services is required by law to maintain the privacy and security of your protected health information.
o We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
o We must follow the duties and privacy practices described in this notice and give you a copy of it.
o We will not use or share your information other than as described here unless you tell us we can in writing. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Patient acknowledges that they have received a copy of this notice and understand their rights within.
Thank you for choosing Boca Mobile Health Services for your primary care needs. Our goal is to provide exemplary care in the place you call home. In order for us to provide these services, consents & financial responsibility must be obtained. I attest that I have received, read and fully understand the following and consent to them fully and voluntarily.
