Consent Forms

Please correct the errors described below.

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.

  1. I understand that the same standard of care applies to a telemedicine visit as applies to an inperson visit.
  2. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.
  3. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
    1. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
  4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
    1. I may revoke my right at any time by contacting MD Progressive Care at 214-521-0100
  5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
  6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
    1. I understand that my insurance carrier will have access to my medical records for quality review/audit.
    2. I understand that I will be responsible for any out-of-pocket costs such as co-payments or coinsurances that apply to my telemedicine visit.
    3. I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.
  7. I understand that this document will become a part of my medical record

By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

General Office Guidelines and Procedures

Consent of Treatment

I, as a patient/legal guardian, do consent for the medical treatment by MD Progressive Care (MDPC), physicians, nurse practitioners and physician assistants, this is inclusive of any treatment or procedure they deem medically necessary.

Authorization to Release Medical Information

This is to serve as authorization to release medical information compiled in the course of medical treatment at MDPC to the undersigned patient. A copy of this will serve as an original.

Acknowledgment of Receiving and Reading a Copy of "Notice of Privacy Practices" and "Patient Rights and Responsibilities"

I acknowledge receipt of MDPC's Notice of Privacy Practices and Patient Rights and Responsibilities. The Notice of Privacy Practice provides detailed information about how MDPC may use and disclose by confidential information. I understand that MDPC reserves the right to change their privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be made available to me upon request.

Tardy and Late Cancellation Policy

In order to best serve all of our patients it may be necessary to reschedule your appointment if you are 15 minutes late or more. Failure to come in for your appointment without giving our office at least 24 hours notice may result in a $35 charge on your account.

Physician Assistant Consent for Treatment

A physician assistant and nurse practitioner are not doctors. A physician assistant and nurse practitioner are graduates of a certified training program and are licensed by the state board. Under the supervision of a physician, a physician assistant or nurse practitioner can diagnose, treat and monitor common acute and chronic diseases as well as provide health maintenance care. “Supervision” does not require the constant physical presence of a supervising physician, but rather overseeing the activities of and accepting responsibility for the medical services provided.

I understand that at any time I can refuse to see the physician assistant or nurse practitioner and request to see a physician.

I have read the information above and consent to all.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Financial Responsibility

Our primary mission is to provide you with quality, cost effective, medical care. Together, we (patients and physicians) are trying to adapt to the changing way that healthcare is financed and delivered. The following letter outlines some of the financial and procedural steps required by your insurance or managed care plan.

Payment Guidelines:

  • We must collect any co-payments, co-insurance, and /or deductibles at the time of service, unless other arrangements have been made in advance with our office.
  • We accept Cash, Checks, Money Orders, & Credit Cards (Visa, MasterCard, Discover and American Express).
  • The remainder of your bill will be sent to your insurance company for payment to our office.
  • If, by mistake, your insurance company remits this payment to you, please send it to us along with all paperwork sent to you. Please do not send the payment back to the insurance company.
  • Any balance that your insurance company determines to be your financial responsibility will be billed to you. Payment is due in full upon receipt of your first statement.

When to Present Insurance Card?

Please present your insurance card at EACH VISIT. Specifically bring to our attention any changes (new card, new group #, etc.) since your last visit. This protects you from paying a bill because we had the wrong insurance information. There is a narrow window (30-45 days) to present an accurate claim to the correct insurance company. Failure to do so could mean the claim may be denied. In addition, if you have a secondary insurance, it will be filed on your behalf as a courtesy. However, if we have not received payment from your secondary insurance in a timely manner, the balance will become your responsibility.

Insurance Company Denies Payment?

Sometimes your insurance company will refuse payment of a claim for some of the following reasons:

  1. This is a pre-existing illness or condition that they do not cover.
  2. You have not met your full calendar year deductible.
  3. The type of medical service required is not covered.
  4. The insurance was not in effect at the time of service.
  5. You have other insurance which must be filed first.
  6. You have exceeded your maximum dollar/visit amount.
  7. You did not have a referral number for your visit/service.

If your insurance company denies your claim for any of the above reasons or for any other reasons, our office cannot be responsible for this bill. It is your responsibility to pay the denied amounts in full at the time of billing. If you would like to contact our billing office, you may reach them at 214-521-0100.

I have read and understand my financial obligations. I understand that this office will file an insurance claim on my behalf. I assign the proceeds of such insurance claim to MDPC. Both MDPC and I will receive an Explanation of Benefits (EOB) from my insurance company that will detail all payments, deductions and adjustments per my plan’s guidelines. MDPC may file a claim for services rendered by the physician and/or facility.

I understand that I will be fully responsible for payment in full at the time of billing of any and all medical services denied by my insurance company determined to be my portion of the billed charges. Balances that remain unpaid after 90 days from the date first billed may be referred to an outside collection agency for further collection efforts.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Consent for Use and Disclosure of Protected Health Information

MD Progressive Care, (MDPC) may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to MDPC's Notice of Privacy Practice for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Procedures prior to signing the consent. MDPC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the MDPC Privacy Officer at 3500 Oak Lawn, Suite 700, Dallas, Texas, 75219.

You may disclose protected health information (PHI about me to the people listed below. (You must include full name.)

Add Person

With my consent, MDPC may email me, any items that assist the practice in carrying out TPO, such as appointment reminders and patient statements. I have the right to request that MDPC restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement

LabCorp and Quest Billing is completely separate from MDPC. If you have any lab billing questions please contact the lab directly.

By signing this form, I consent to MDPC's use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance to prior consent.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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