Consent for Treatment and Privacy Policy

Consent for Treatment and Notice of Privacy Practices for Health Information (NPP) Acknowledgement
In this document, SoCal Emergency Medicine is referred to as Clinic and person acknowledging this document is referred to as You or Patient. You acknowledge and agree to all of the following:
1. Consent to treatment, which may include examination, drug screening, laboratory procedures, x-ray, local anesthesia, surgical procedures, and other clinical services.
2. The law provides that the consent of the Patient be obtained so that the clinic may use or disclose medical information to the Patient.
3. Insured Patients: We will bill the Patients insurance company for all the services provided during the clinic visit. Co-payments, co-insurance, and deductibles required by the insurance company must be paid by the Patient and payment may be requested before or at the time of service. In addition, if the insurance company denies all or part of the payment, the Patient agrees to be responsible to pay the amounts that are due to the clinic under the law. By acknowledging this form, you authorize us to submit a claim for payment to the Patient’s insurance company for services provided to the Patient. You also authorize the insurance company to make direct payments to us for such services.
4. Uninsured Patients: Patients who do not have insurance must pay the Clinic for the services provided at the time of service at our fee schedule.
5. Additional Terms: All past due accounts will be charged interest at the legal rate. If we refer the Patient’s account to a collection agency or an attorney, the Patient agrees to pay the clinic’s reasonable attorneys’ fees, costs, and collection expenses.
6. No Refunds will be issued for the office visit once an evaluation by the provider has been made.
The law requires that SoCal Emergency Medicine give to a patient a copy of its Notice of Privacy Practices for Health Information. We will give you a copy at the time of the first treatment and, if we change our notice, thereafter at the next treatment visit.