(Please fill out all 3 pages completely)
Authorization for treatment: I voluntarily consent to the administration and cost of medical and surgical procedures for myself or my dependent.
Assignment of insurance benefits: I authorize payment direct to NJ Doctors Urgent Care, LLC for all benefits otherwise payable to me.
Guarantee of Payments: I understand that I am financially responsible and agree to pay all charges that are not paid or billed to insurance or any other third party payer. I understand that I must pay in full today for all services rendered unless my insurance is accepted. I also understand that if my insurance accepted, I must pay all applicable insurance co pays, coinsurances and deductibles today. If you are unable to verify my insurance at time of services, I will in pay in full for all services.
Release of Records: I authorize NJ Doctors Urgent Care, LLC to release (verbal or in writing) confidential medical information to any person or entity including my insurance carrier, employer if treatment is related to employment purposes, or other health care operation which may be liable to me or my practitioners for charges for this treatment and for quality management, utilization review, transfer, and follow up purposes.
Receipt of Privacy Practices:I acknowledge that I have received and read the Notice of Privacy Practices of NJ Doctors Urgent care, LLC. I understand that copy of this agreement may be used with the same effectiveness as the original.
I, the undersigned, consent to the care and treatment by the attending physician, his/her associates or assistants. I acknowledge that no guarantees have been made as to the effect of such treatment.
I voluntarily present for treatment and consent to my physician and whomever they may designate as their patient care staff to provide my care. Such care may include, but not limited to, diagnostic procedures, x-rays, blood draw, laboratory tests, medication administration, and other procedures considered advisable in my diagnosis, treatment, and course of care. I acknowledge that no guarantee can be made or has been made as to the results of treatments or examination at NJ Doctors Urgent Care.
With my consent, NJ Doctors Urgent Care, may use and disclose personal health information (PHI) about me to carry out treatment, payment and healthcare operations. Please refer to the NJ Doctors Urgent Care Notice of Privacy practices for a complete description of such uses and disclosures.
I acknowledge that treatment at NJ Doctors Urgent Care is intended to address specific episodic illnesses or injuries and is not intended as a substitute for a primary care physician or other specialized physician. This consent shall remain in force until such time as it is specifically revoked in writing.
With my consent NJ Doctors Urgent Care may call home, cell phone or other designated number/person to leave a message on voice mail or in person in reference to any items that assist the practice in carrying out treatment, payment or health care operations such as appointment reminder, insurance items, and pertaining to my clinical care including laboratory/radiology results. I authorize and designate this person to receive above mentioned communications from the office. This consent in in effect until revoked in writing by me.
We at NJ Doctors Urgent Care are required by law to maintain the privacy and provide individuals with a copy of Notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to the Notice, please ask to speak with our HIPAA Compliance Officer. If you would like a copy of the Notice, Please ask. I consenting to NJ Doctor’s Urgent care’s use and disclosure of my personal health information to carry out treatment, payment and healthcare operations.
If you are being seen today for Covid-19 testing, please note that you will NOT be called with negative results. ONLY Positive results will be called. You must use the patient lab portal to obtain your results by logging on to our website www.njdoctorsurgentcare.com. Cell phone number is required to gain access to the portal.
