INFORMED CONSENT AND FINANCIAL RESPONSIBILITY
WellVet Health Centre
By receiving healthcare services at WellVet Health Centre, I (as the patient, parent, guardian, spouse, guarantor, or other responsible party) consent to and authorize medical treatment and diagnostic procedures that may be ordered and/or provided by my doctor or healthcare provider, and performed at WellVet Health Centre facilities, including internal medicine, general medicine, physical therapy, and psychology services.
Furthermore, I consent to receiving medical treatment through telehealth modalities (e.g., tools that enable remote audio and/or video interaction between the patient and the healthcare provider) and/or remote patient monitoring (RPM) tools, collectively referred to as “Telehealth.” These services will be provided confidentially, and information will not be disclosed without proper consent. I authorize physicians or designated healthcare professionals to provide necessary and/or recommended treatment via Telehealth. I understand that other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain the confidentiality of the information obtained. I acknowledge that I have the right to request that my healthcare provider discontinue the Telehealth encounter at any time.
I understand that there are potential risks associated with this technology, including the possibility of the video connection failing during the encounter, the video image or transmitted information not being clear enough to be useful, or being asked to visit the consulting physician’s physical location if it is determined that the information obtained via Telehealth is insufficient to make a diagnosis.
FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF INSURANCE BENEFITS
WellVet Health Centre is authorized to release any medical information required for processing applications or submitting information for financial coverage, including information related to psychiatric care, drug and alcohol abuse, sexual assault, or tests for infectious diseases, including HIV/AIDS, for services provided during this visit. I also agree to the release of medical or other information to government regulatory agencies (federal or state) as required by law. For FMP, Champ/VA, Tricare beneficiaries, I have provided all necessary information for the proper assignment of benefits.
In exchange for the services provided and to be provided by WellVet Health Centre, I irrevocably assign and transfer to WellVet Health Centre all rights, titles, and interests in all benefits payable for the healthcare rendered, which are covered under any insurance policies or health benefit plans from which I am entitled to recover, including but not limited to hospitalization, medical, third-party liability insurance coverage, workers’ compensation benefits, employer, employer group, individual, welfare benefit, trust-sponsored plans, and benefits paid by FMP, Champ/VA, Tricare. This assignment includes any interest in benefits I may have related to the current date of service as well as any prior dates of service.
By executing this assignment of benefits, I request that all insurance companies pay WellVet Health Centre directly for the services provided. I understand that any payment received from these policies and/or plans will be applied to any outstanding balance I may have with WellVet Health Centre. Additionally, I understand that I am not entitled to a refund unless all WellVet Health Centre bills are paid in full. If a third party is obligated to pay some or all of these charges, I agree to take all necessary actions to assist VellVet Clinic in collecting payment from such third-party payer. I appoint VellVet Clinic as my authorized representative to pursue, at its discretion, all administrative remedies, claims, appeals, and/or lawsuits on my behalf against any responsible third party, medical insurer, or employer-sponsored medical benefit plan for the purpose of collecting any and all hospital benefits due for the payment of charges. I authorize VellVet Clinic to endorse and retain benefit checks made payable directly to me.
I understand that VWellVet Health Centre may bill an insurance company as a courtesy to me but is not obligated to do so. I understand that if WellVet Health Centre initially accepts health insurance coverage, this does not waive its right to collect or accept, as payment in full, any payment made under different coverage or benefits or any other sources of payment that may cover expenses incurred for services and treatment. I acknowledge that Professional Services may be provided by independent contractors and are not part of WellVet Health Centre’s bills. I understand that care deemed experimental by my insurance company may not be covered, and I will be responsible for those charges. I agree that if my account is not paid, it may be turned over to a collection agency or attorney, and I must pay the amount due plus all collection costs, including reasonable attorney fees and costs.
I have read and had the opportunity to ask questions about this assignment of benefits, and I agree to these terms freely and without inducement, except for the provision of services by VellVet Clinic.
FOREING MEDICAL PROGRAM PATIENT CERTIFICATION (For FMP Patients Only)
I certify that I have provided information about all insurance coverage available to me. I authorize WellVet Health Centre to release to the Foreing Medical Program, its intermediaries, or carriers any information needed for this or a related FMP claim. I authorize the payment of benefits to WellVet Health Centre.
GUIDELINES FOR RELEASE OF INFORMATION SPECIFIC TO ALCOHOL AND SUBSTANCE PROGRAMS
The release of information regarding a patient involved in alcohol and drug programs at WellVet Health Centre is governed by strict Federal Confidentiality Laws. Federal Regulations (42 CFR Part 2) prohibit WellVet Health Centre from disclosing any information without the written consent of the person to whom the information pertains. Federal laws and regulations do not protect information about a crime or a threat to commit a crime, or any information regarding suspected abuse or neglect, from being reported to the appropriate authorities.
HIPAA (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT) DISCLOSURE/USE OF HEALTH INFORMATION NOTIFICATION
I certify that I have reviewed and/or received a copy of the Notice of Privacy Practices. I understand that the uses and disclosures of my personal health information are described in the Notice of Privacy Practices provided.
