I hereby consent to treatment by OneCare Health- Advanced Practice Health & Wellness, LLC.
I authorize the medical team, including the nursing staff as well as any students or residents (although they may not be licensed to practice, but completed a course of study in the respected discipline) to provide medical care including telehealth services and to administer diagnostic, radiological and or therapeutic procedures and treatments as the medical team determines is necessary or advisable in my care or for the care of an obstetrical patient or a pediatric patient. If I am singing this document on behalf of another person, I acknowledge that I am consigning on behalf of said patient and I will indicate the relationship (parent, relative, health care agent, guardian, surrogate) where indicated below. I authorize release of certain information including but not limited to immunization records to state and/or federal registries. If at any time a member of the health care team involved in your care becomes exposed to hazardous bodily fluids that could result in the transmission of a bloodborne disease, such as Herpes, Hepatitis, HIV or Syphilis as well as other potential bloodborne disease, a blood sample will be obtained from you, the patient and tested for said diseases in an effort to rule out any exposure to the health care member.
I acknowledge that this form authorizes release of my HIV, Hepatitis and other potential bloodborne communicable disease results to the healthcare worker who was exposed and their healthcare provider for purposes of providing post-exposure care. I understand that these individuals are prohibited by law from re-disclosing my testing results in a way that could reveal my identity.
I acknowledge that this form authorizes my healthcare team to discuss information related to my post discharge support and care with an individual named as my caregiver. I understand that if I have provided Emergency Contact names that OneCare Health- Advanced Practice Health & Wellness, LLC considers these individuals as my “designated representative(s).” This facility may share my protected health information with my designated representative to the extent permitted by law and to the extent that I have directed otherwise.
- I understand that OneCare Health- Advanced Practice Health & Wellness, LLC is not responsible for any errors that may occur at the laboratory. I understand that the laboratory is solely responsible to process the collected specimen once received by OneCare Health- Advanced Practice Health & Wellness, LLC. In the event of a lab error, OneCare Health- Advanced Practice Health & Wellness, LLC will recollect the sample at a discounted rate, at the written request of the patient. Any error made by OneCare Health- Advanced Practice Health & Wellness, LLC will be corrected at no extra charge; so long as all documentation was submitted adequately prior to appointment.
- Laboratories may bill your insurance company directly for the testing of the collected specimen. Any billing questions or issues for tests collected for this service should be directed to your insurance company or the laboratory billing department.
- Please be advised that OneCare Health- Advanced Practice Health & Wellness, LLC is not responsible for any outstanding balances with the designated performing laboratory and will need to be settled prior to testing services. The laboratories have the right to decline specimens of patients with outstanding balances. If your testing is declined due to outstanding balances owed to the laboratory, OneCare Health- Advanced Practice Health & Wellness, LLC will not reimburse any services performed.
- In accordance with New York State law the laboratory will report all findings for the following tests to the New York State Department of Health and Mental Hygiene: COVID-19, and any other tests required by law. A copy of all results may also be sent to your primary care physician.
Electronic medical records: I authorize OneCare Health- Advanced Practice Health & Wellness, LLC to retrieve my health records and any medications I am currently communicating through EMR/EHR software and e-prescribing systems and allow them to be imported into my electronic medical record here at OneCare Health
I allow OneCare Health- Advanced Practice Health & Wellness, LLC to provide me with medical treatment. I allow OneCare Health- Advanced Practice Health & Wellness, LLC to file any insurance claims / benefits to collect compensation for the care that was rendered to me on the day of my visit. I understand that:
- OneCare Health- Advanced Practice Health & Wellness, LLC will need to communicate details of my visit today to my insurance company and to OneCare Health- Advanced Practice Health & Wellness, LLC’s billing solutions provider.
- I must pay for any of the treatment received today that is not covered by my insurance company.
- I do not have insurance coverage and agree to pay the balance in full for today’s visit.
- I have the right to refuse any procedure or treatment.
- I have the right to discuss all medical treatments with my clinician.
I acknowledge that all diagnosis (s), treatments and therapeutic interventions that were recommended to me were clearly explained including the purpose of each of them. The “risks & benefits” as well as “alternative to treatments” have also been clearly explained to the best of my knowledge. I have been given the opportunity to discuss these treatment options and have all my questions and concerns, if any addressed by the health care provider/team.
At this time:
I have no questions in regards to the recommended treatment plan. All information has been communicated to me in a clear and concise manner and it meets my satisfaction.
I understand that the practice of medicine, chiropractic care and any other health services / profession is not an exact science and I acknowledge that no guarantee has been made to me regarding the outcome of my treatment. I have made my decision regarding the treatment that I wish to receive freely and voluntarily and waive my right to seek legal action / council, bring upon claims for any of what I have signed above. By signing below, I hereby give my permission and consent to OneCare Health- Advanced Practice Health and Wellness, LLC and all of its affiliates and contractors to receive treatment.
I am at least 18 years of age or my parents, guardian, or an agent is singing on my behalf. I am cognizant, lucid and oriented. Fluent and proficient in understanding the English language and if not, assistance was/is provided/offered to me by an interpreter/translator