Telehealth Consent – Broward Community & Family Health Centers

Broward Community & Family Health Centers, Inc.

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CONSENT FOR TREATMENT

The undersigned patient and/or authorized relative/legal guardian hereby consents to authorize Broward Community & Family Health Centers, Inc., its facilities or treatment centers, and affiliated physicians, dentists, surgeons, and other medical personnel, to administer and perform any and all medical examinations and treatments that may now or during the course of the patient’s care be necessary or advisable and further agree to hold Broward Community & Family Health Centers, Inc., its affiliates and medical personnel, harmless for all such medical treatments.

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Patient/Authorized Guardian*

Relationship to Patient*

Date*

Select Primary Care Site*

Email*

Phone*

METHOD OF PAYMENT

How do you intend to pay for your treatment? (Check all that apply)*

Self

Medicare

Private Insurace

If other (Specify)

AGREEMENTS

1st agreement*

I agree to be responsible for payment for all charges incurred for my medical care at Broward Community & Family Health Centers, Inc. facility or treatment center and/or its affiliates. If I have private insurance, I agree to be responsible for paying the deductibles, co-payments and for any other non-covered services rendered.

2nd agreement*

Medicare currently covers me. I agree to be responsible for the charges associated with meeting any Medicare deductible and the 20% co-payment on all Medicare charges. I further agree to be responsible for paying the supplemental insurance deductibles and/or co-payments and/or for any other non-covered services rendered.

3rd agreement*

By signing this form, I hereby accept that I have read and understood the acknowledgment letter provided above. I declare that the information I have provided above is correct.

By my e-signature below:

I authorize the release of any medical information, including any HIV (AIDS), mental health, and/or substance abuse test (s) and results necessary to process all health insurance claims (current and supplemental) to Medicare, Medicaid, insurance company (s), physicians (s), and/or other health care facility or health care providers to whether this facility may refer the patient. I further agree to release Broward Community & Family Health Centers, Inc., its facilities, treatment centers, and its affiliated personnel from all legal responsibility and/or liability that may arise from the release of such records and waive all rights I have to preserve their confidentiality.
I authorize Broward Community & Family Health Centers, Inc., its facilities or treatment centers, and its affiliates, to verify my information with my employer(s) and/or inform my employer(s) in a worker’s compensation claim(s).
I authorize payment of all medical benefits directly to Broward Community & Family Health Centers, Inc., or its affiliated facility treatment center as designated.

Full Name*

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Broward Community & Family Health Centers, Inc.

CONSENT FOR TREATMENT

METHOD OF PAYMENT

AGREEMENTS

By my e-signature below:

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