Consent Form

One of our pharmacies shared their consent to treat and bill privacy information form. 

Please feel free to look over, modify, etc for your use. 

Consent Form

Consent to Treat/Bill & Privacy Information Form

Thank you for choosing _______________________________ . Please review the form below so we
can provide the optimal care for you, bill appropriately, and share your information securely.

CONSENT FOR TREATMENT
By signing this form, I consent to and authorize my provider(s) _______________________
to treat me or my dependent. I understand this could include lab tests, , immunizations, medication
prescription and/or administration, education, other diagnostic tests, or behavioral health
interventions. My provider may also bill for cognitive services such as disease state monitoring,
medication education and general healthcare screenings such as height, weight, blood pressure and
oxygen saturation. I understand that my provider is available to explain the treatment and I have the
right to refuse treatment. I understand that this consent will be valid and remain in effect as long as I
attend any of the clinics at ___________________________.

CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION
I hereby authorize ____________________________ to release any information acquired in the
course of my examination and treatment to any authorized agent for the purposes of healthcare,
treatment, and payment. I authorize the release of medical, dental, and/or behavioral health
information to my insurers as necessary for determination and payment of benefits; to utilization
review and professional standards review organizations, companies, and community resources that
assist me with my healthcare needs.

NOTIFICATION OF PRIVACY
________________________ complies with the Health Insurance Portability and Accountability Act of
1996 (HIPAA). I have received the __________________ Notice of Privacy Practices and Medicare
Patients’ Bill of Rights.

CONSENT TO BILL, ASSIGNMENT OF BENEFITS, AND PAYMENT
I authorize _____________________________ to file a claim with my insurance carrier for services
rendered. I authorize ________________ payment of benefits directly to ____________________,
for services provided to my dependent or me. I understand that I am responsible for any part of the
charges that are not covered/paid by my insurance, and I will be billed directly for those services. I
recognize that the billing statements and EOB’s will have the specific name of our clinic and that of
our Collaborative Practice Physician.
** If you are uninsured, please note that your account is your responsibility. No patient will be
denied services due to his/her inability to pay. Discounts for essential services are offered
dependent on income and household size as compared to the current federal poverty guidelines.
Please inquire for more details. The parent or legal guardian of a minor patient (under 18 years of
age) is responsible for payment on the minor’s account.

ACKNOWLEDGEMENT OF PERSONAL PROPERTY
I understand that ____________________ shall not be liable for loss or damages of any personal
property.
______________________________ endorses supports and participates in the
HEALTH INFORMATION EXCHANGE
__________________________participates in state, local and federal Immunization Information
Connection System. _________________________ is a statewide immunization information system
that stores electronic immunization records. _________________________ combines
immunizations a person has received into a single record, even if the vaccines were given by
different health care providers in the state

BENEFITS/RISKS OF BEHAVIORAL HEALTH TREATMENT
Potential benefits include better relationships, solutions to specific problems, improved
understanding of yourself, and relief from unpleasant emotions. There may be some risks including,
but not limited to addressing painful emotional experiences, being challenged or confronted with a
particular issue, or being inconvenienced due to the costs of services. Opiate, alcohol and
psychiatric screenings are simply tools that ______________________________ will utilize to best
assess an issue and will convey all relevant findings to your health care team. They are to be used as
diagnostic tools and not treatment plans.

MENTAL HEALTH CRISIS/EMERGENCY
If you have a mental health crisis or need to speak to someone, please call Suicide Prevent Lifeline at
800-273-TALK (8255) at any time, or call 911, or go to your nearest hospital emergency department;
they are there to help you.

LIMITS OF CONFIDENTIALITY
We are permitted or required, under specific circumstances, to use or disclose protected health
information without your written authorization: suicidal urges (being a danger to yourself),
homicidal urges (being a danger to others), court order/subpoena, child abuse/neglect, and elder or
vulnerable adult abuse/neglect.
I understand that I may revoke this consent in writing; however, my revocation will not apply to
information already used or released in reliance on this consent. I agree that a copy of this consent may
be used in place of the original. I also understand that by refusing to sign this consent or revoking this
consent, this organization may not be able to provide services to me.
My signature below indicates that I understand and accept the content of this form.

Signature Date
Patient or Patient Representative (print name)
If not the patient: Relationship to Patient:

The Legal Stuff:

* This is not property of Mobile MediClaim. Use at your own risk. Mobile MediClaim does not warrant or guarantee.

Mobile MediClaim may collaborate with various third-party providers to offer a comprehensive range of services and products to our valued customers. These third-party providers are independent entities and have their own terms and conditions, privacy policies, and liability practices.

1. Liability and Indemnification: a. Mobile MediClaim shall not be held liable for any defects, damages, or issues arising from the use of products or services provided by third-party providers. b. By choosing to avail yourself of any third-party products or services, you acknowledge and agree to indemnify and hold Mobile MediClaim, its employees, agents, and affiliates harmless from any claims, damages, or liabilities arising from your use of such third-party products or services. c. It is your responsibility to read and understand the terms and conditions, warranties, and disclaimers provided by the third-party providers for their products or services.

2. Disclaimer of Endorsement: a. The inclusion of any third-party products or services within our offerings does not constitute an endorsement or recommendation by Mobile MediClaim. We provide access to these products and services for your convenience, but we do not warrant or guarantee their performance, safety, or suitability for your specific needs. b. We encourage you to conduct your own research and due diligence before using any third-party products or services to ensure they meet your requirements.

3. Reporting Issues: a. If you encounter any problems or concerns related to third-party products or services, please report them to Mobile MediClaim as soon as possible. b. We will make reasonable efforts to facilitate communication with the third-party provider to address your concerns, but we cannot guarantee the resolution of the issue.

By using this form, you acknowledge that you have read and understood the terms and conditions outlined above. You further agree that you will not hold Mobile MediClaim, its employees, agents, or affiliates liable for any issues related to third-party products or services.