I consent to customary care which consists of, but is not limited to: nursing services, administration of medications and intravenous therapy, noninvasive diagnostic procedures, and routine laboratory work (including random drug screening) as ordered by the physician when necessary as a patient at Emergency One Urgent Care and Diagnostic Center.)
I am aware:
I have the right to be treated with courtesy, respect and dignity.
I have a right to receive from the physician or other health care professional any and all information about invasive, non-routine procedures that are proposed to me.
I have the right to consent or refuse to consent to any proposed treatment while a patient at Emergency One.
I have the right to privacy as described in HIPAA.
I have the right to an interpreter.
I have the right to submit a complaint or grievance for follow up by Emergency One.
I have the right to receive accurate and easily understood information about my healthcare professional and healthcare facility.
I have the right to refuse the release of personal health information (except when permitted by law or in regard to work status).
I have the right of access to, and request for, amendment of my medical records.
I acknowledge that no guarantees of cure have been made to me as a result of examination or treatment while here at Emergency One.
I further consent to the necessary transfer of medical information about me for purposes of insurance, workers’ compensation , including fitness to return to work, or transfer to another facility or physician for continuation of my care, if necessary.
I understand that if I submit to a drug screen for an employer or potential employer, the results will be released to that employer or potential employer.
As a patient of Emergency One, I have the following responsibilities to assist in my medical care:
I have the responsibility of full disclosure of medical information to assist in establishing a diagnosis and an appropriate plan of care.
I have the responsibility to support an environment where the safety and property of Emergency One’s personnel and other patients are respected.
I have the responsibility to inquire if any portion of my care-giving or follow-up are not entirely comprehended.
I have the responsibility to notify the staff or medical provider if there are any limitations (cultural, religious or other) that may limit my care or pose barriers to providing care.
In the event that a service is not covered by my insurance company, I will be responsible for payment to Emergency One.
I authorize insurance payment of medical benefits for the services rendered.