Thank you for entrusting River City Retina Consultants with your care. This consent form outlines the terms and conditions for medical care and treatment provided by our doctors. By signing this document, you acknowledge that you have read, understood, and agree to the information provided. This includes an understanding of our commitment to providing high-quality care, the nature of ophthalmic examinations and treatments, and your rights and responsibilities as a patient.
1. Consent for Health Care Services: You voluntarily consent to care that involves routine diagnostic tests, procedures, and medical treatment as prescribed by your physician and performed by River City Retina Consultants. No guarantees have been given by anyone as to the results that may be obtained. You consent to photographing, videotaping, video monitoring and audio devices for medical, safety or identification purposes. You understand that these will be stored in a secure manner that will protect your privacy. Images that identify you will only be released when authorized by you or as needed to provide for your continued medical treatment.
2. Authorization for Release of Information: River City Retina Consultants may release information from your medical records to any health care provider involved in your care and treatment. River City Retina Consultants may also release information from your medical records to any person or organization liable for all or part of your charges, such as your insurance carrier, any third-party payer, the Medicare programs, and your employer’s workers’ compensation carrier. You acknowledge that upon the disclosure of medical record information to an insurance company or other payer pursuant to this authorization, River City Retina Consultants is no longer responsible for the confidentiality of any information known or possessed by the payer. You authorize River City Retina Consultants to file an appeal of a payment denial and/or request a hearing regarding any denial of payment for treatment provided to you. You further authorize the facility to present proof, utilize facility records and your records and documentation for appeals and hearings.
You will disclose specific individuals that River City Retina Consultants may share medical information with in the Emergency/Alternate Contacts space of the demographic form. If you wish to add additional individuals, you will request an Authorization for Release of Medical Records form. You understand that processing the form may take up to 30 days.
3. Responsibility for Loss of Personal Articles: You understand that River City Retina Consultants shall not be liable for the loss of or damage to any money, jewelry, documents, or any other items of personal property. Furthermore, you accept full responsibility for items of personal property kept in your possession.
4. Behavioral Policies: You understand and agree to adhere to the behavioral policies for River City Retina Consultants, encompassing all property, whether owned, leased, or rented, as well as online and in-person interactions. You also understand that any visitors who accompany you or communicate on your behalf are required to follow these same policies. You acknowledge that failure to comply with these guidelines may result in your dismissal from the practice and/or other actions deemed necessary by River City Retina Consultants. A full copy of the policies is available upon request.
5. Financial Agreement: You understand that there is no guarantee of payment from any insurance company or other payer. You agree to pay all charges for the services provided by River City Retina Consultants which are not paid by your health insurance or other payer. All charges are due and payable when you receive the bill. You understand that any credit or refund that you may be owed will be forwarded to the address on file with River City Retina Consultants. You understand that after reasonable notice, typically sent at 30, 60, and 90 days, delinquent accounts may be turned over to a collection agency and/or an attorney for collection. Should it be necessary to place this account in the hands of an attorney for collection, you agree to pay the costs of collection, including any court costs and a reasonable fee to the attorney employed by River City Retina Consultants to collect the account. You agree that the facility, its employees, agents, attorneys, and collection agencies, may call or text the cell number you provide for any reason, including but not limited to inquiring about the status and collection of your account. You also expressly authorize that each of them may use any mechanism including but not limited to automatic dialing, artificial and pre-recorded voice systems.
Self-Pay Option
Additionally, you understand that you have the right to a “Self-Pay” visit in which your medical information will not be shared with your insurance company. Should you decide to do this, you will notify River City Retina Consultants as soon as possible.
6. Pre-authorization Requirements: You accept the responsibility to obtain all referrals or pre-authorizations and to comply with all requirements of any insurance or medical coverage plan upon which you are relying for medical coverage of River City Retina Consultants charges.
7. Assignment for Direct Payment: You authorize that payment of any insurance (including auto insurance and health-care insurance) benefits for health care services or goods may be made directly to River City Retina Consultants.
8. Calling, Texting, and Emailing: You agree that all telephone numbers and email addresses you provide to River City Retina Consultants may be used by River City Retina Consultants or those acting on its behalf to communicate with you by telephone (including cell phone), unencrypted text messages, or any automated or prerecorded messages. You understand that such unencrypted text messages may be intercepted by unauthorized individuals and you understand and accept the risk of using unencrypted communications. You will be given an option to opt-out or unsubscribe from most communications. For those communications that don’t offer an opt-out or unsubscribe option, you will call the office at (502) 897-9881 and ask to be removed from the list. We will not communicate protected health information via text or email.
You acknowledge that:
You have read this form and understand its contents.
You are the patient, or person duly authorized either by the patient or otherwise, to sign this agreement, consent to, and accept its terms.
You are responsible for the payment and/or co-payment that is due at the time of service.
You have received, or have been offered, a copy of River City Retina Consultants HIPAA Policy.
