Consent to Treatment
The undersigned consents to the performance of medical services,
administration of medications and, other medical procedures (“Services”) by
(“Provider”) at CityHealth Urgent Care, as deemed appropriate by Provider’s
medical personnel. I understand that medical care is not an exact science and
no guarantees have been made regarding the outcome of treatment. I
acknowledge that I have reviewed and agree with the Consent to Treatment.
Release of Information
I authorize Provider and any other holder of information about me to disclose all
or any part of my medical record or other information needed to determine my
eligibility for benefits or the amount of benefits payable for Services rendered
by Provider, now or in the future, to any financially responsible party, including
but not limited to: the Centers for Medicare and Medicaid (CMS), Medicaid,
their intermediaries or carriers, Worker’s Compensation carriers, health or
liability insurers, or any other insurance organization or billing agent (collectively,
“Insurer”). I authorize any holder of medical and billing information about me to
release to Provider or any Insurer any information necessary for billing and
payment purposes. I consent to the use of a copy of this authorization in lieu of
I acknowledge that I have reviewed and agree with the Release of Information.
Assignment of Benefits
I request and authorize direct payment to Provider of any Medicare and other
insurance benefits payable to me or on my behalf for Services rendered by
Provider, now or in the future. At Provider’s election, I also assign to Provider all
of my rights and interest in all such insurance benefits or proceeds, including
but not limited to the right to appeal any denial of benefits or to file any lawfully
authorized lien necessary to secure payment from any third party or a third
party’s Insurer. I understand that I am financially responsible for the services
rendered by Provider and agree to immediately remit all payments received
from insurance for those services. I agree to cooperate with Provider or its
agent in collecting any such benefits. This assignment shall not obligate
Provider to file any appeal or perfect any such lien and nothing herein shall
relieve me from direct financial responsibility for any charges not paid by an
I acknowledge that I have reviewed and agree with the Assignment of Benefits.
Payment in full is due at time of service. I acknowledge that many Insurers will
only pay for services that they determine to be medically necessary and that
meet other coverage requirements. For example, some Insurers require prior
authorization for certain services. If my Insurer determines that the Services, or
any part of them, are not medically necessary or fail to meet other coverage
requirements, the Insurer may deny payment for that Service. Notwithstanding
any other provision herein, I agree that if my Insurer denies all or any part of
Provider’s charges for any reason, or if I have no insurance, I will be personally
and fully responsible for payment of Provider’s charges. Should my account be
referred to an attorney or collection agency, I agree to pay actual attorney’s
fees and collection expenses. All delinquent accounts shall bear interest at
twelve percent per annum, not to exceed the maximum amount permitted by
Credit Card Authorization Agreement/Consent
If you have provided your insurance information during your visit today, our
billing team will send a claim to your insurance company shortly after your visit.
Once the claim is processed, your insurance company will send us an
Explanation of Benefits (EOB) with the amount you owe. If you have a remaining
balance, we will charge the credit card you have left on file with us, for that
remaining balance. If you have any questions regarding your balance, please
notify our Billing Team at [email protected] or call 925-753-0198.
By signing this form, you are consenting to leave a credit/debit/HSA or FSA
card on file with CityHealth Urgent Care. Your information will be stored using
the same encrypted, secure software used to store your medical records. You
are also consenting to have your card charged for any remaining balances.
I acknowledge that I have reviewed and agree with the Financial Responsibility.
The undersigned certifies that he/she has read the foregoing, and is the
patient, the patient’s legal representative or is duly authorized by the patient
as the patient’s agent to execute this Conditions of Service and Consent to
Treat and to accept its terms.