PATIENT INFORMED CONSENT
Please review and complete the form on the next page.
Description of Services
The Healthcare Professionals at Advanced Care provide healthcare services in person and/or interactive audio and video technologies called Telehealth where you and the Healthcare Professional are not in the same physical location. You can form an ongoing treatment relationship with a Healthcare Professional, however, your initial visit may begin as a consultation (e.g. to determine the most appropriate treatment setting for you to receive care) and will not necessarily give rise to an ongoing treatment relationship. You should seek emergency help or follow-up care when recommended by a Healthcare Professional or when otherwise needed and continue to consult with your other healthcare providers as recommended. Among the benefits of our Services are improved access to healthcare and convenience. However, as with any health service, there are potential risks associated with the use of technology.
These risks include, but may not be limited to:
In rare cases, information transmitted may be insufficient for healthcare decision making.
Disruptions can occur due to failures of the electronic equipment or internet connection. If this happens, you may be contacted by phone or other means of communication.
In rare cases, a lack of access to all of your health records may result in adverse drug interactions or other errors.
Although we incorporate strong security protocols to protect the confidentiality of your health information, in rare instances security protocols can fail, causing a breach of confidentiality.
By accepting this consent, you acknowledge that you understand and agree with the following:
If your health insurance coverage does not pay for your Services charges in full, you may be fully or partially responsible for payment.
We may determine that our clinical services are not appropriate for some or all of your treatment needs and may elect not to provide clinical services to you through the Site.
You attest that you have legal authority to act as guardian or personal representative of all children registered under your Account.
No results can be guaranteed or assured.
You can send messages to a Healthcare Professional by contacting our Member Support team at 1-866-835-2546. Emails or electronic messages to staff and healthcare provider may not be returned immediately. If you are experiencing a medical emergency, you should call 911 or go to the nearest emergency room.
*Advanced Care practice is a group of professional practice collectively known as “Advanced Care Nursing Corporation”.
I certify that the information given to me in applying for payment under Title XVII of the Social Security Act is correct. I authorize release of all records required to act on this request. I understand that I will not be charged for services covered and payable by Medicare. The agency will inform me if the services become no longer covered under Medicare.
I hereby authorize direct payment to the Advanced Care Nursing Corporation (ACNC) of any insurance benefits payable to me for services rendered at a rate to exceed the agency’s regular charges. It is agreed that payment to the agency, pursuant to this authorization, by an insurance company shall discharge said insurance company of any and all obligations under the policy to the extent of such payment. I authorize release of all records required to act on this request. I understand I will be billed for applicable co-payment and deductibles per my insurance policy. I understand and agree that should there be no, or insufficient, insurance to pay for services given to me by ACNC, that I will pay for such services.