CONSENT FOR MEDICAL TREATMENT

I hereby consent to the procedures which may be performed during this examination, including services which may include but are not limited to laboratory procedures, x-ray examination, diagnostic procedures, medical, and/or surgical treatments or procedures, anesthesia or other urgent services rendered to me under the general and special instruction of a Duke City Urgent Care Provider.

NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that I have received the notice of privacy practices (below), which describes the ways in which Duke City Urgent Care may use and disclose my healthcare information for treatment, payment of services, healthcare operations and other described and permitted uses and disclosures.

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

I hereby authorize the payment directly to Duke City Urgent Care, LLC for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for any and all charges not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the doctor and/or any provider or supplier of services in this office to release any information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. I further acknowledge that I have received and read the financial policy for Duke City Urgent Care. I understand and agree to the financial policy.

FINANCIAL AGREEMENT

In consideration of the services rendered to the patient, the undersigned (as parent, guardian, spouse, guarantor, and agent or as the patient) individually promises to pay the patient’s account at the rates established by the clinic for services provided. A receipt of charges for services to the patient is available upon request. All final charges are based on multiple factors, including but not limited to the course of treatment, intensity of care, physician practices, and the necessity of providing additional goods and services.

I hereby consent, acknowledge and fully understand the above. I also understand there are no guarantees or assurances from anyone as to the results that may be obtained from any medical treatment or services rendered at Duke City Urgent Care.

CONSENT FOR MEDICAL TREATMENT

I hereby consent to the procedures which may be performed during this examination, including services which may include but are not limited to laboratory procedures, x-ray examination, diagnostic procedures, medical, and/or surgical treatments or procedures, anesthesia or other urgent services rendered to me under the general and special instruction of a Duke City Urgent Care Provider.

NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that I have received the notice of privacy practices, which describes the ways in which Duke City Urgent Care may use and disclose my healthcare information for treatment, payment of services, healthcare operations and other described and permitted uses and disclosures.

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

I hereby authorize the payment directly to Duke City Urgent Care, LLC for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for any and all charges not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the doctor and/or any provider or supplier of services in this office to release any information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. I further acknowledge that I have received and read the financial policy for Duke City Urgent Care. I understand and agree to the financial policy.

FINANCIAL AGREEMENT

In consideration of the services rendered to the patient, the undersigned (as parent, guardian, spouse, guarantor, and agent or as the patient) individually promises to pay the patient’s account at the rates established by the clinic for services provided. A receipt of charges for services to the patient is available upon request. All final charges are based on multiple factors, including but not limited to the course of treatment, intensity of care, physician practices, and the necessity of providing additional goods and services.

I hereby consent, acknowledge and fully understand the above. I also understand there are no guarantees or assurances from anyone as to the results that may be obtained from any medical treatment or services rendered at Duke City Urgent Care.

CREDIT CARD/DEBIT CARD AUTHORIZATION

Duke City Urgent Care, LLC submits claims to insurance carriers as a convenience to all our patients.  If you have either a high deductible health plan or a co-insurance, or if we are unable to verify eligibility at the time of your visit, we request authorization to balance bill a major credit card or debit card to cover amounts determined by your insurance to be your responsibility.

Upon receipt of an explanation of benefits from your insurance carrier, you will be sent a statement explaining the amount due from you.  You will then have the opportunity to contact Duke City Urgent Care within 14 days to pay via cash, check, or credit card.  In the event that you do not contact Duke City Urgent Care within 14 days, any unpaid portion of your claim will be billed to your credit or debit card up to a maximum of $250.  Should your insurance pay in full, your account will not be charged.

All credit card/debit card information will remain absolutely confidential and securely stored by First Data.  Duke City Urgent Care, LLC will not store any banking account or credit card data.

Your consent authorizes Duke City Urgent Care LLC to charge any and all outstanding balances, after insurance company reimbursement or denial and appropriate communication with you, to your credit/debit card.

CONSENT TO SMS COMMUNICATION

I hereby consent to the use of SMS text communication by Duke City Urgent Care for the purposes of appointment reservations, registration, and reminders; Lab result communication; General communication for healthcare concerns, issues and enquirers by Duke City Urgent Care staff. SMS communication is facilitated by the Duke City Urgent Care EHR & Clinical Automation Platform (Athena & Decoded Health). No SMS information will be shared with third parties/affiliates for marketing/promotional purposes. Please refer to our SMS Terms and Conditions Privacy Policy for further information.

INFORMED CONSENT FOR TELEMEDICINE SERVICES

Introduction

Telemedicine involves the use of electronic communications to enable health care providers at different locations to charge individual patient medical information for the purpose of improving patient care.  Providers may include Doctors, Nurse Practitioners, or Physician Assistants.  The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

Patient Medical Records

• Medical Images
• Live two-way audio and video
• Output data from medical devices and sound and video files
• Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure it’s integrity against intentional or unintentional corruption.

Expected Benefits

• Improved access to medical care by enabling a patient to remain in his/her home or business while the provider obtains test results and consults from healthcare practitioners at distant/other sites including across state lines.
• More efficient medical evaluation, management, and treatment.
• Obtaining expertise of a distant specialist.

Notice of Privacy Practices for Protected Health Information

Original Effective Date: March 9, 2015

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

The Duke City Urgent Care (DCUC) clinic is permitted by federal privacy laws to make uses and disclosures of your Protected Health Information (PHI) for purposes of treatment, payment and other healthcare operations. The terms “we” and “our” is defined to include all employees of the clinic and any providers identified for services in conjunction with DCUC.

Protected health information (PHI) is the information we collect and obtain to provide medical services. Information may include but not be limited to; Diagnosis,Treatments, Results of tests performed from present and past visits for future medical determinations.

Examples of uses of your health information for treatment purposes are:

• The clinic will use and disclose your protected health information in coordination and management of your health care and any related medical services.
• A sign in sheet will be used and visible to other patients, staff and those who enter the clinic. The use of the sign in sheet will be strictly for business practices.
• PHI will be used for coordination and management of your medical needs with a third party provider, for reason of treatment for continued medical care. In some cases, we may also disclose information to an outside treatment provider for purpose of the treatment activities of the other provider (for example, disclosing PHI to a pharmacy to fill a prescription or to a obtain results of a lab test not available on site).

Examples of use of your health information for payment purposes:

• Your PHI will be used as needed to obtain payment for any and all services rendered and/or required. This includes any communications between payer sources and the clinic (for example, services may require prior authorization for services; insurance payer would be contacted to obtain information regarding benefits, eligibility and medical necessity).

Examples of reasons for public interest and benefit activities permitted (not required in recognition of the important uses made of PHI outside of healthcare context with specific conditions and limitations, refer to HHS.gov for more information) to disclose PHI without an individual’s authorization by federal regulations include:

• Public health authorities are authorized by law to collect or receive information for preventing or controlling disease, injury, or disability and to public health or other government authorities authorized to receive reports of child abuse and neglect;
• FDA regulation regarding FDA regulated products or activities for purposes such as adverse event reporting, tracking of products, product recalls, and post marketing surveillance;
• Individuals who may have contracted or been exposed to a communicable disease when notification is authorized by law;
• Employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury or workplace related medical surveillance.
• Victims of Abuse, Neglect or Domestic Violence. In certain circumstances, regulations require disclosure of PHI to appropriate government authorities regarding victims of abuse, neglect, or domestic violence.
• Health Oversight Activities may require PHI to be disclosed for the purpose of legally authorized audits and investigations necessary for oversight of the health care system and government benefit programs, by such agencies as assigned by the government.
• Judicial and Administrative Proceedings may require the disclosure of PHI through an order from a court or administrative tribunal. This may be in response to a subpoena or other lawful process.
• Law Enforcement Purposes may require PHI to be disclosed to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; to identify or locate a suspect, fugitive, material witness, or missing person; in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; to alert law enforcement of a person’s death, if the covered entity suspects that criminal activity caused the death; when a covered entity believes that protected health information is evidence of a crime that occurred on its premises; and by a covered health care provider in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime

The health and billing records we maintain are the physical property of the clinic, however; the information is available to you. You have the following rights;

• To review and obtain a copy of your PHI in your medical record.
• To request that DCUC restrict use or disclosure of PHI for treatment, payment or health care operations, disclosure to persons involved in the individual’s health care or payment for health care, or disclosure to notify family members or others about the individual’s general condition, location, or death.
• To request an amendment of your PHI in your Medical Record when the information is inaccurate or incomplete.
• To disclose all accounts of your PHI by DCUC or other medical providers or entities.

CONSENT TO AUDIO RECORDING OF PATIENT VISIT

Patient consents to Duke City Urgent Care recording of patient visit for the purposes of documenting the encounter.  Duke City Urgent Care may use ambient listening on the phone or computer to assist in creating notes.  Patient acknowledges and understands that their physician must review, update, and sign the encounter records to ensure accuracy.  Patient recognizes that audio recordings will be kept in a manner consistent with the Duke City Urgent Care HIPAA Privacy notice and that all recordings are destroyed within 7 days of the patient visit.

SMS TERMS AND CONDITIONS PRIVACY POLICY

The use of patient SMS is solely for the health communication purposes between Duke City Urgent Care and it’s patients.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All of the above categories exclude text messaging originator opt-in data and consent; this information will now be shared with any third parties.

Duke City Urgent Care offers the option to our patients to receive text reminders, communications and information regarding their healthcare and appointments for that care. Message frequency varies. Message and data rates may apply. Reply STOP to cancel. If you require assistance please text HELP to (205)350-8000. Carriers are not liable for any delays or undelivered messages.

DCUC Responsibilities are as follows :

• We are required to maintain the privacy of your health information and to provide you with the notice of our duties and privacy practices.
• We are required to abide by terms of this notice as may be amended from time to time.
• We reserve the right to change the terms of this notice and to make the new notice provisions effective for all future PHI that we maintain. If we change the notice we will provide a copy to any persons with such request by means of in person or via US postal services.
• As a health care provider we will in good faith make an effort to obtain written acknowledgment from you in receipt of the privacy practices notice provided to you.

For More Information

If you have any questions or concerns in regards to this Notice of Privacy or feel your rights have been violated, contact the Medical Director at Duke City Urgent Care located at 11601 Montgomery Blvd NE Albuquerque, New Mexico 87111 during business hours or contact the clinic at (505) 814-1995.

You may also file a written complaint to the US Dept. of Health and Human Services, Office for Civil Rights at 1301 young Street-Suite 1169 Dallas, Texas 75202.

You will not be retaliated against or penalized for any complaints filed against or any issues brought to the attention of the clinic.