Request for Care and Consent for Treatment
The undersigned consents to the medical care and treatment, as may be deemed necessary or advisable in the judgment of my physician or other provider, which may include but are not limited to laboratory procedures, X-ray examination, medical or surgical treatment or procedures or other services rendered to the patient under the general and special instructions of the the patient's physician. Gastro Florida has the right to refuse to treat you if you refuse to sign this consent or it, at any time, you choose to revoke this consent.
Permission for Treatment
Permission is hereby granted for physicians and employees or agents of Gastro Florida to render such medical and surgical treatment as is deemed necessary to the patient named below.
Assignment of Insurance Benefits
I authorize payment directly to Gastro Florida of any insurance benefits otherwise payable to me for services, at a rate not to exceed Gastro Florida regular charges for such services.
Authorization to Release Information
I authorize the release of medical records and related information from Gastro Florida to authorized representative of my third party payor or provider related to my care. I authorize review of records for any necessary agency audit and the release of the physician plan of care and discharge summary from my medical record upon my transfer to or from another health care facility.
By providing my email and phone number(s), I authorize Gastro Florida to provide me information regarding my appointment (e.g. visit reminder), billing status, and/or educational material that may be related to my condition(s), in addition, to periodically inform me of Gastro Florida services/community events and requesting feedback regarding my experience with Gastro Florida. I can opt out at any time by emailing firstname.lastname@example.org to make this request. I understand that emailing confidential information may not be a HIPAA compliant secure form of communication and that Gastro Florida does not monitor emails for specific patient care.
I authorize Gastro Florida to enroll me in its secured patient portal that may also include the above information along with my clinical test results and medications. I understand that I should not rely on the portal to communicate important or emergency information regarding my specific care.
I authorize Gastro Florida to include my patient survey or online review comments on its website or promotional material (note: your last name will not be used.)
The undersigned certifies that he/she has read the foregoing, received a copy thereof and is the patient or is duly authorized by the patient as patient's general agent to execute the above and accepts its terms.