Medical Omnibus Consent Form

Medical Omnibus Consent Form

Parties and Identifying Information

Recitals

WHEREAS, Patient Name: desires to receive medical evaluation, treatment, and related services from Provider Name: ; and

WHEREAS, Provider is duly authorized and qualified to render medical, diagnostic, telehealth, and ancillary services and the Parties wish to set forth the scope of consent, financial arrangements, data release permissions, and other terms governing the provision of such services;

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the Parties agree as follows:

Scope of Consent and Services

Patient hereby consents to the following categories of care and related actions as may be reasonably necessary or advisable during the term of this Consent Form. Patient initialing does not limit Provider's professional judgment in emergent situations.

Payment Terms

Patient agrees to pay Provider for services rendered in accordance with the schedule and rates set forth below. Provider may charge for office visits, procedures, telehealth visits, diagnostic testing, and ancillary services.

Patient also authorizes Provider to bill and collect from health insurers, governmental payors, and third-party payors, and to provide necessary information to such payors. Patient acknowledges responsibility for amounts not covered by payors.

Term and Termination

This Consent and Agreement shall commence on Start Date: and continue until End Date: unless sooner terminated in accordance with this section.

Either Party may terminate this Agreement for convenience by providing written notice to the other Party at least Notice Period (days): in advance. Provider may terminate immediately for nonpayment or if continued care would be detrimental to Patient's health. Termination shall not affect obligations accrued prior to termination, including payment and confidentiality obligations.

Confidentiality and Release of Information

Provider shall maintain the confidentiality of Patient's protected health information (PHI) in accordance with applicable law. Patient authorizes Provider to use and disclose PHI, as necessary, for treatment, payment, and healthcare operations, and to communicate with designated family members or caregivers as indicated below.

Notwithstanding the foregoing, Provider may disclose PHI as required by law, to avert a serious threat to health or safety, or pursuant to court order. Confidentiality obligations shall survive termination of this Agreement.

Assumption of Risk; Revocation of Consent

Patient acknowledges that all medical procedures carry risks and that Provider has explained the nature, risks, benefits, and alternatives to recommended treatments to the extent reasonably practicable. Patient understands that this consent may be revoked in writing at any time, except to the extent Provider has already acted in reliance on this consent or where revocation would jeopardize Patient's care.

Governing Law; Dispute Resolution

This Agreement shall be governed by and construed in accordance with the laws of the State specified below. Any dispute arising out of or relating to this Agreement shall be resolved in the state or federal courts located in the applicable jurisdiction, and each Party hereby consents to exclusive jurisdiction and venue in those courts.

Representations; Entire Agreement

Each Party represents and warrants that it has the authority to enter into this Agreement and that the person signing below is authorized to bind the Party. This Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether written or oral. Any amendments must be in writing and signed by both Parties.

Indemnification and Insurance

Patient agrees to indemnify and hold harmless Provider from claims, liabilities, and expenses to the extent caused by Patient's negligence or failure to provide accurate medical history. Provider shall maintain professional liability insurance in amounts consistent with industry practice.

Acknowledgement and Certification

By signing below, Patient certifies that Patient has read and understands the terms of this Medical Omnibus Consent Form, that all responses on this form are true and complete to the best of Patient's knowledge, that Patient has had the opportunity to ask questions and has received satisfactory answers, and that Patient consents to the scope of services and financial terms set forth above.

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