Be Well Medical, PLLC Client Contract
Client name: _________________________________________ Client date of birth: ______________
As either the client or the legally authorized representative of the client, on behalf of the client receiving care with Be Well Medical, PLLC, I make the following consents, understandings, and agreements on my own behalf and on behalf of the client, in consideration of health care services to be provided to the client:
Welcome and thank you for choosing Be Well Medical, PLLC for your healthcare needs. We are dedicated to providing quality medical care to our clients. Please review the below information regarding your care with Be Well Medical, PLLC. Please let us know if you have any questions or concerns regarding the following information.
I understand that all information disclosed within sessions or during visits is kept confidential and is not revealed to anyone without my permission. I understand that Be Well Medical is a Primary Care Clinic that offers telehealth virtual visits. I give my permission for Be Well Medical to discuss my care with my healthcare team so that collaborative care plans can be made in my best interest.
I further understand that there are specific and limited exceptions to this confidentiality, which include the following: When there is risk of imminent danger to myself or to another person, the clinician is ethically bound to take necessary steps to prevent such danger. When there is suspicion that a child, elder or vulnerable adult is being neglected, sexually or physically abused, or is at risk of such abuse, the clinician is legally required to take steps to protect the child or adult, and to inform the proper authorities. When a valid court order is issued for medical records Be Well Medical practitioners are bound by law to comply with such requests.
Consent to Treat
I hereby give consent to Be Well Medical practitioners: Andrea Skates, FNP, Savannah Alder, FNP, Erica Steele, FNP and any contractors, and employees to provide healthcare services to the client and to administer provider orders for the benefit of the client for this visit and any subsequent visits. I understand this consent may be revoked in writing at any time. I understand there is a risk of substantial and serious harm of any particular involved in such health care services, and I accept such risk in the hope of obtaining beneficial results from such services. No promises of any particular outcome or successful result have been made. I understand that that providers (nurse practitioners, dietitians, nutritionists, and therapists) are separately responsible to explain what they do, and in some cases, such as medical procedures, to obtain separate consent for some of the services they perform.
I understand that some health care providers furnishing service to the patient, including interns and professionals in training/students may be independent contractors and not employees of Be Well Medical, PLLC, which are subject to provisions of the Utah Governmental Immunity act, UCA 63-30-1, et seq., U.C.A. 1953 as amended, which controls all procedures and provisions with respect to any claim of liability or malpractice involving such individuals.
I understand that Andrea Skates, Savannah Alder, and Erica Steele are licensed family nurse practitioners who are licensed to order medical testing, prescribe medications, diagnose, treat, and perform specific medical procedures within the state of Utah.
I understand it is my responsibility to be accountable for my own health. If I do not hear from someone to help schedule additional testing or schedule with a referred provider/specialist, I understand it is my responsibility to notify my practitioner/clinic so that I can get assistance in doing so. I understand it is my responsibility to notify my practitioner about any side effects, worsening conditions, or lack of improvement I may be experiencing. If my symptoms suddenly worsen, I agree to either contact the clinic and notify my practitioner or seek urgent/emergent care if appropriate.
If patient is a minor, a legal guardian must also sign the form. If parents are divorced, informed consent must be signed by whoever is declared in the divorce decree as custody holder(s). For example, if there is joint custody both parents MUST sign the informed consent. A copy of the divorce decree is needed by the 2nd session/visit to continue therapy if both parents do not sign the informed consent.
By signing the Informed Consent, you voluntarily agree to receive health assessment, care, treatment, or services and authorize the therapist and nurse practitioner to provide such care, treatment, or services as are considered necessary and advisable. Signing indicates that you understand and agree that you will participate in the planning of your care, treatment, or services, and that you may stop such care, treatment, or services at any time. By signing the Informed Consent, you acknowledge that you have both read and understood all the terms and information contained herein.
Consent to share healthcare information:
I authorize you to release my personal healthcare information (such as testing results) to the individual(s) listed in the emergency contact, and understand this release is valid unless I request in writing to revoke the authorized person.
Privacy Practice and Release of Information
Visits/Gathering information: During initial and subsequent visits, my provider will gather information about me and my history. I understand that it is my responsibility to help gather accurate information. This includes providing up-to-date medication lists with doses, bringing copies of prior treatment records (if available or if they can be reasonably obtained), and being as honest and forthcoming as possible. My provider will recommend, and I am responsible to follow through with closely spaced follow up visits after medication changes (such as starting new medications, tapering off medications, or dose changes, or wellness plans) and during times of medical need.
Scheduling Policy: I understand it is my responsibility to schedule follow up appointments as advised. The receptionist is only available to reschedule appointments during business hours and I will make an effort to call during these times whenever possible. I agree to pay a $40 fee for missing scheduled appointments or for failing to cancel an appointment 24 hours in advance (a voicemail message is acceptable if the receptionist is unavailable as long as it is at least 24-hour notice). I understand that if I am more than 15 minutes late for a scheduled appointment, I may be asked to reschedule my appointment and I will be charged a $15 service fee. If I have not been seen in 1 year or more, I understand that I will no longer be considered an active patient. To resume care through my provider, I would then need to be scheduled as a new patient, depending on availability and make sure any unpaid balance on my account is paid in full. I agree to inform the Be Well Medical if my contact information changes during the course of treatment.
Payment and Financial Policy: Be Well Medical, PLLC accepts most major insurances. Co-payments/co-insurance is due at the time of service. As a courtesy to you, Be Well Medical, PLLC will submit bills directly to your insurance company as per the information you provide us. Your cooperation in giving complete information including insurance company name, address, telephone number, policy number and group number will assist in getting your insurance claim paid quickly. A copy of your insurance card is also requested. Self pay is also an option if there is not insurance or if your insurance is not accepted at Be Well Medical, PLLC.
PAYMENT OF YOUR BILL
Regardless of the type of insurance coverage, you are ultimately responsible for payment of your medical bills. If insurance is accepted, then reasonable efforts will be implemented to obtain payment from your insurance company. If they reject the claims or do not pay within 60 days payment will be your responsibility. Payment of known deductibles, co-pays and non-covered services is expected at the time of service. After reasonable collection efforts have been made any account balance not satisfied will be turned over to an outside collection agency. You are responsible for any finance, collection or attorney fees associated with collection of the unpaid balance.
I have read the FINANCIAL POLICY STATEMENT and understand that any charges incurred are my responsibility and I have given correct billing information. I understand that I will be responsible for any finance, collection or attorney fees associated with collection of these charges.
Should your account be turned over for collection, the undersigned agrees to pay all costs to collect the debt, including, but not limited to, interest in the amount of 18% per annum, attorney’s fees, court costs, and collection fees in the amount of 40%. The obligation to pay the collection fees shall be imposed at the time of assignment of the debt to a third party debt collection agency.
Medication History Authority: I grant authority to Be Well Medical, PLLC to download medication history automatically from pharmacy benefit managers (PBMs). This allows continuity of care, promotes safety during prescribing, and medication management. By not allowing access to prescribed medications, I am responsible for increasing potential risk and harm to myself by not disclosing all medications being prescribed.
Assignment of Benefits: Any and all benefits from insurance companies and other third party payors that are payable to the client or on behalf of the client for healthcare services and related payments for services rendered or provided to the client are hereby transferred and assigned to Be Well Medical, PLLC for the exclusive purpose of paying for charges associated with the health care services provided to the client. I understand and intend that all insurance companies and other third party payers will pay benefits directly to the provider in payment of the incurred charges and the charges of any other healthcare providers authorized to bill in connection with healthcare services provided to the patient.
I understand that Be Well Medical, PLLC is a non-emergent Family Medicine Practice and telehealth virtual clinic. I understand that I am to call my pharmacy for refill requests on medications. If I am feeling worse or my symptoms are not improving, I understand it is my responsibility to either seek emergent/urgent medical care or contact the clinic. If I have an emergency (including suicidal ideation), I agree to call 911 or go to the nearest hospital. If I have urgent medical needs that occur after hours, I understand I need to go to an urgent care center.
The undersigned signs this document either as the patient or as the agent or representative of the client authorized to execute this document and to accept and agree to its terms on behalf of the client. I have read the foregoing and have had the opportunity to ask any questions I may have about the foregoing. Such questions have been answered to my satisfaction and I indicate my full understanding by signing below. I understand that I am entitled to request and obtain a copy of this document. This document will remain in effect unless revoked in writing.