Assignment and Release
You are not required to sign and return this form. You will have the opportunity to discuss and acknowledge this form during your telephone visit.
I understand and agree that:
- I am financially responsible for all non-covered services, copays, deductibles, and/or coinsurance.
- I am financially responsible for all fees generated for services, supplies, and equipment provided by an outside specialist (e.g. lab work) and that the outside specialist may bill me directly for those fees.
- Benefits of insurance are assigned to CHAS Health.
- These terms are non-negotiable. Attempts to modify these terms are void and my acceptance of
healthcare services constitutes my full agreement with these terms
- I may receive healthcare through telephone or video connection, referred to as Telehealth. While telehealth has several benefits including increased access to healthcare, there are risks. I have the right to refuse treatment through telehealth at any time. Risks related to malfunctioning equipment or poor phone or internet connection may disrupt or delay care. In-person visits may be required. In very rare instances, security protocols could fail causing a breach of privacy or personal medical information. Please refer to the CHAS Notice of Privacy Practices for more information about how we secure private data.
- I authorize CHAS Health to communicate with me using unsecured SMS text messaging, regarding my health care that may include protected health information. I understand that exchanging email, text, or other written communications with my care team can result in the disclosure of protected health information to unauthorized persons and that CHAS cannot control who views such information when sent unsecured. If I initiate or respond to communications using unencrypted pathways, I assume the risk that my information may be seen by a third party.
I understand that I may opt-out of texting by replying 411stop at any time.
I understand that I am not required to consent to receive text messages to receive services and that I may elect to sign a different form that excludes this text message consent.
I understand that I am responsible for any costs associated with my receiving text messages, including data fees from my wireless carrier.
- I authorize CHAS Health to contact me by telephone to remind me of appointments or to discuss my protected health information.
- If I fail to keep my appointment or provide late notice of cancellation (within 4 hours of scheduled appointment) three in a three-month period, I may be restricted to same day only scheduling or walk-in status
I authorize my provider’s office to contact me by telephone to remind me of my appointments.