Healthcare DispatchHealth Agreement

Healthcare DispatchHealth Agreement

This Healthcare DispatchHealth Agreement (Agreement) sets forth the terms under which Provider: DispatchHealth will provide on-site or remote clinical services to the undersigned patient. Patient Name: Date of Birth: Medical Record Number (if known):

Patient Information

Emergency Contact

Insurance & Billing

Medical History

Description of Services & Consent to Treatment

I authorize and consent to the administration of clinically indicated evaluations, diagnostic tests, medications, procedures, and treatments by DispatchHealth clinicians as deemed necessary for my care. I understand that all medical care involves risks and potential complications, including but not limited to allergic reaction, infection, bleeding, adverse drug reaction, or failure to achieve the intended result. I have had the opportunity to ask questions regarding the nature, risks, benefits, and alternatives to the proposed care and I acknowledge that such questions have been answered to my satisfaction.

I consent to the provision of medical care by DispatchHealth clinicians in accordance with the terms of this Agreement.

Financial Responsibility & Assignment

By signing this Agreement I authorize DispatchHealth to bill my health insurer and assign benefits for services rendered. I understand that I am financially responsible for any deductible, co-payment, co-insurance, non-covered services, and amounts not paid by my insurer. I acknowledge that if my insurance does not pay in full, I remain responsible for payment for services provided.

I authorize DispatchHealth to submit claims and to receive insurance payments on my behalf. I authorize release of pertinent medical information to payers as necessary to process claims.

HIPAA Authorization & Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the Provider's Notice of Privacy Practices and that DispatchHealth may use and disclose protected health information for treatment, payment, and health care operations consistent with federal and state law. I authorize the release of my medical information to my designated emergency contact, treating physicians, and payers as necessary for care coordination and billing.

I acknowledge receipt of the Notice of Privacy Practices and authorize disclosures as described above.

I authorize DispatchHealth to discuss my care and disclose relevant medical information to my emergency contact listed above.

Limitations, Withdrawal, and Notices

I understand that I may revoke this authorization at any time by submitting written notice to the provider, except to the extent that action has already been taken in reliance on this authorization. I understand that revocation will not affect disclosures already made in reliance on this authorization. DispatchHealth may refuse to provide certain services if I revoke authorization for treatment or billing in a manner that prevents necessary care or payment.

Operational & Safety Acknowledgments

I acknowledge that home or on-site care requires a reasonably safe environment for clinicians. I agree to inform DispatchHealth if there are hazards, pets, or conditions that may affect provision of care. If emergency transport is required, DispatchHealth will arrange transfer to the appropriate facility and I consent to such transfer when clinically indicated.

I consent to evaluation and treatment via telehealth or remote communication when offered as part of my care.

Authorization Period

This authorization and consent are effective on the date signed below and remain in effect until revoked in writing or until:

Acknowledgment and Certification

I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that providing false information may affect my care and eligibility for coverage. I accept financial responsibility as described herein and authorize my insurer and other payers to remit payment to DispatchHealth for services rendered.

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