Consent to Telehealth Services

You hereby consent to treatment through a telehealth visit. During this visit, details of your medical information, examinations, x-rays, and tests will be discussed with health professionals using interactive video, audio, and telecommunication technology for diagnosis, follow-up and/or educational purposes. You acknowledge that you understand you will not physically be in the room with your healthcare provider.

All existing laws regarding your access to medical information and copies of your medical records apply to this telehealth visit. Video, audio and/or photo recordings may be taken of you during the service, however, not all telecommunications are recorded and stored. Dissemination of any patient-identifiable images or information for this telehealth visit to other entities shall not occur without your consent. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth visit, and all existing confidentiality protections under federal and state law apply to information disclosed during this telehealth consultation.

You acknowledge that risks may occur, which include, but are not limited to technical problems with transmission of information, equipment failures that could result in lost information or delays in treatment. You also acknowledge that you have had the opportunity to discuss any questions or concerns regarding telehealth services with your healthcare provider.

You understand you have the right to withhold or withdraw consent to the telehealth visit at any time without affecting your right to future care or treatment.

Authorization to Treat

You agree to give authorization to receive treatment by our medical staff and release Patients First its Owners, Physicians, Physician Assistants, and Nurse Practitioners, and/or any clinical staff member from any liability claims that may result from any treatment, medications, and/or procedures that have been provided to you. You may be seen by a Nurse Practitioner or Physician Assistant, who are highly qualified to meet the medical needs of our patients. If you do not wish to be treated by a Nurse Practitioner or Physician Assistant, please inform a Patients First team member.

Financial Policy

All account balances, co-pays, and self-pay charges are due prior to services being rendered. If a self-pay patient, final incremental patient charges will be determined based on the self-pay schedule after the visit is rendered. For patients with insurance, any additional patient charges will be determined after filing with the relevant insurance carriers and charged separately at that time.

Accounts with a balance must be paid prior to being seen. For delinquent/bad debt accounts, we reserve the right to turn the account over to a collection agency. Once your account is transferred to a collection agency, all further correspondence must be with them. Having your account in collections could interfere with us providing your medical care in our office.

As a courtesy, we will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. We ask that you leave a credit card on file in the event you may owe a balance.

Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. In the event that your insurance fails to pay for services rendered at Patients First (e.g., deductible not met, out-of-network charges, denial of claim, cancelation of coverage, etc.), in signing this, you agree to be responsible for any remaining balance, with the exception of an adjusted contractual agreement, within sixty (60) days of service. Beyond 60 days, balances may incur a late payment penalty fee up to the maximum allowed by law and/or may be turned over to a third-party collection agency. You also agree that to service your account or collect monies that you may owe, we may contact you by telephone at any number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you may provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing devices, as applicable.

Patients who are self-pay and those with insurance should be aware that we cannot give an exact price for your services prior to you seeing the provider. Charges will depend upon the services rendered for your care and your particular insurance plan.

Payment can be made by: Cash, Check, or most Major Credit/Debit Cards.

All returned checks, stop payments, and credit card disputes/reversals will incur a fee of $30.00.

All products sold in our office are non-returnable.

For our patients without insurance, payment for a Basic Office Visit is expected prior to being seen. If there are costs associated with any additional services provided to you, payment for these services must be paid in full prior to departure from the center.

For our patients with insurance, all account balances and co-payments are required at time of service.

Ancillary Service Notification

In reading this, you understand that Patients First may determine it to be necessary to send lab specimens to an outside laboratory, send x-rays taken at Patients First’s Urgent Care centers to an outside radiologist for over-read, or provide durable medical equipment or supplies deemed necessary during your visit. Charges incurred for these services may be billed to you separately by that vendor.

Patients First utilizes certain outside labs that may be able to deliver your lab results the next day, allowing your medical care providers to know the results faster and be more precise in prescribing the most appropriate treatment plan for you. Using a lab that provides faster results may be more expensive, and you may be responsible for this cost if your insurance does not cover it. If this is necessary, the provider on duty will discuss these options with you.

Text Messaging and Communications

By providing a mobile number, you consent to receive text messages regarding your experience, payment, and appointment information from our automated system. You can choose to opt out of receiving text messages regarding your experience and billing. To opt out of all messaging, you can choose not to give us your mobile number. Giving us your mobile number is not a condition of service; however, we do ask that you give us a way to contact you quickly so that we are better able to communicate with you regarding your medical care.