ExpressCare - Waivers



Telemedicine Consent to Treat

1. I understand that my health care provider wishes me to engage in a telemedicine visit.

2. I understand how the video conferencing technology used to accomplish such a visit will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. My questions have been answered and any practical alternatives have been discussed with me in a language in which I understand. I further understand that I will be informed of who is present during the telemedicine visit and have the right to terminate the telemedicine visit at any time.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine visit if it is felt that the videoconferencing connections are not adequate enough for the situation.

4. I have had the alternatives to a telemedicine visit explained to me, including scheduling a face to face in office visit with my health care provider. By acknowledging this form, I certify: I have read or had this form read and/or explained to me That I fully understand its contents, including the risks and benefits of telemedicine visits That I have been given ample opportunity to ask questions and that the questions have been answered to my satisfaction.

5. I understand that the audio or video portion of this visit will not be recorded by ExpressCare Urgent Care Centers other than written documentation in my medical record. I also understand that I may not record this session by any means without permission of ExpressCare Urgent Care management.

Signature: _______________________________ Date: __________________ (patient/parent/conservator/guardian)

ExpressCare Managed Care Service Release/ Card on file payment

I authorize treatment by ExpressCare for the reason that I presented at ExpressCare. I understand that if appropriate, ExpressCare will bill my Health Plan for services to be rendered. However, I also understand that pursuant to Maryland law, ExpressCare is authorized to bill me under the following conditions:

I. When I choose to receive services covered under my benefit plan without a referral and/or authorization from my Health Plan, I understand that my Health Plan may require that I get a signed referral from my primary care physician and/or authorization from my Health Plan to receive covered services. If my Health Plan determines that I did not get a referral and/or authorization when I should have, I understand that I am responsible for payment for the services rendered.

II. When I receive services that are not covered under my benefit plan, and if my Health Plan decides that the services I receive are not covered under my benefit policy, I understand that I will be responsible for payment for the services rendered. This includes Telemedicine visits.

III. When I receive any type of testing after being triaged at ExpressCare, and I then elect to leave prior to being seen by a Provider, I will be responsible for paying out of pocket for those tests that were performed. These charges will be paid prior to leaving center.

ExpressCare Urgent Care Centers submit claims to insurance carriers as a convenience to all of our patients. Due to rising nonpayment of bills, we request authorization to bill a major credit card or debit card to cover amounts determined by your insurance company to be your responsibility. We recommend using a credit card.

Upon receipt of an explanation of benefits from your insurance carrier any unpaid portion of your claim will be billed, in accordance with your insurance carrier’s determination of “Patient Responsibility”, to your credit card or debit card automatically. Please note that the timing of this transaction is determined by your insurance company. ExpressCare may be able to send an email prior to this transaction. We advise having funds available for 1 year from today’s date of service. In the event your insurance pays your visit in full, your card will not be charged.

All patients that have a deductible plan with a remaining deductible balance, must either provide a credit card to be stored in Vantiv for any fees not paid by insurance company, OR pay the required deductible fee prior to visit. All credit/debit card information will remain absolutely confidential and securely stored by Vantiv. ExpressCare Urgent Care Centers will not store any banking account data.

I hereby authorize ExpressCare Urgent Care Centers to charge any and all outstanding balances, up to $300.00 after insurance company reimbursement or denial, to my credit/debit card. I understand that I will not receive a statement if there is no balance due after processing my credit/debit card for payment.

I acknowledge receipt of the ExpressCare Managed Care Service Release.

Signature:_______________________________ Date:__________________ (patient/parent/conservator/guardian)

PAYMENT POLICY

I agree to be responsible for all charges not otherwise paid by third-party insurance. I understand that I am fully responsible for charges incurred for medical services received, which charges I expressly agree are reasonable. In the event that my account is referred to any attorney for collection, I agree to be responsible for and to pay my bill and all court cost, private process fees, and other cost of collection as well as attorney’s fees in the amount of 20% of my bill, which sum I expressly agree is reasonable. In the event that my check is return unpaid for any reason whatsoever, I agree to pay in addition to the amount of the check the greater of twice the amount of the check plus a $35.00 administrative charge or the maximum amount allowed by law. I acknowledge that this sum is a reasonable amount to compensate ExpressCare for the costs incurred by the issuance of any returned check. I understand that this is an agreement under seal and subject to a twelve statute of limitations.

I acknowledge receipt of the ExpressCare Urgent Care Center’s Payment Policy.

Signature: _______________________________ Date: __________________ (patient/parent/conservator/guardian)

EXPRESSCARE URGENT CARE CENTER NOTICE OF PRIVACY PRACTICES and ACKNOWLEDGEMENT OF RECEIPT and AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

By signing this form, you acknowledge receipt of the ExpressCare Urgent Care Center Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full. In addition your information may be shared through our hospital affiliation with Lifebridge Health.

I authorize ExpressCare and its affiliates (collectively, “ExpressCare”) to release to ExpressCare’s business partner, LifeBridge Health, Inc., and its affiliates and agents and members of their medical staff (collectively, “LifeBridge”) information relating to the care I receive from ExpressCare, for the following purposes: ⦁ arranging for follow-up care ⦁ coordinating the care I receive from ExpressCare with care that I have received, or may in the future receive, from LifeBridge ⦁ Enabling LifeBridge to contact me regarding services that it offers that may be of interest to me, such as primary care.

I understand that I need not sign this authorization in order to receive services from ExpressCare. LifeBridge will have the right to share the information it receives from ExpressCare in accordance with the LifeBridge Health Notice of Privacy Practices, which may be viewed at http://www.lifebridgehealth.org/Main/HIPAA.aspx.

I may revoke this authorization by giving notice in accordance with ExpressCare’s Notice of Privacy Practices, which can be obtained at the registration desk of any ExpressCare location. This authorization expires one year from Date of Service.

I acknowledge receipt of the ExpressCare Urgent Care Center Notice of Privacy Practices.

Signature:_______________________________ Date:__________________ (patient/parent/conservator/guardian)

 

Notice: Medicare will only pay for services that it determines to be "reasonable and necessary" under section 1862 (a) (1) of the Medicare law. If Medicare determines that a particular service, although it would otherwise be covered, is not "reasonable and necessary" under Medicare program standards, Medicare will deny payment for that service.

Beneficiary’s Acknowledgement & Agreement to Pay:

If Medicare denies the payment for services rendered today, I agree to personally and fully responsible for payment.

Patient Signature: ________________________________________________  Date:____/_____/___

CRISP WAIVER

Chesapeake Regional Information System for our Patients ExpressCare Urgent Care Centers has chosen to participate in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and disable access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org. Public health reporting and Controlled Dangerous Substances information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), will still be available to providers.

____ I have read the waiver and agree to participate in the CRISP program to better assist in the coordination of my care. ____ I will be opting out of participation in the CRISP program. For Telemedicine patients, please verbalize this opt out to provider.

Name__________________________

Signature______________________________

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