Consent and Authorization for Routine Treatment
I consent to and authorize Emergensea, LLC dba “Blue Med Consultants”, my physicians and health care providers (collectively my providers”) to provide or order the routine medical care, diagnostic and laboratory procedures, which my providers believe to be necessary.
I understand and acknowledge that Emergensea, LLC dba “Blue Med Consultants” has zero tolerance for harassing, aggressive or violent behavior by its visitors, staff, and patients. I agree that neither I nor my visitors will photograph, film, or record any provider without that provider’s express consent.
Disclosure of Patient Information
I authorize Emergensea, LLC dba “Blue Med Consultants” and my providers to release my health information (including information relating to mental health/psychiatric care, alcohol and/or substance abuse, genetic testing, and HIV tests) and any other information for treatment purposes and/or to obtain payment for charges incurred by me or on my behalf to: my providers or any affiliated provider; my referring or treating providers; any third party engaged in the collection or dissemination of my medication information; the guarantor on my accounts; any third party payors (defined as including, but not limited to, Medicare, Medicaid, Tri-care or governmental programs; health, accident, automobile or other insurance; workers’ compensation payers, agents or administrators; HMOs; self-insured employers; and any sponsors who may contribute payment for medical services) or their agents; regional or national health information networks; and other providers of medical services and products related to or connected with this admission or course of Care.
I authorize Emergensea, LLC dba “Blue Med Consultants” to disclose my patient information to: business associates, public health and oversight agencies, regulatory entities, other health care providers or organizations who have provided me with Care to facilitate health care operations of any of these parties; residents, interns, students, and others in furtherance of educational purposes; disaster relief agencies as necessary to assist in their endeavors; law enforcement to correctly identify me or to report a crime; affiliated charitable foundations in connection with fundraising programs; and Emergensea, LLC dba “Blue Med Consultants” to send health promoting or informational materials to me.
I hereby assign to Emergensea, LLC dba “Blue Med Consultants” and my providers payment from Medicare, Medicaid and all third party payers with whom I have coverage or from whom benefits are or may become payable to me, for the charges I receive for, related to, or connected with Care (past, present, or future) I receive from Emergensea, LLC dba “Blue Med Consultants” and my providers. I agree to be personally responsible for payment for all Care that is not covered by my third party payers, including, but not limited to, non-covered or out-of-network services, deductibles, co-insurance, and/or co-payments.
By signing my initials, I acknowledge that I have read, understand, and agree to the foregoing as applicable to me and/or my minor child(ren), if provided Care by or on behalf of Emergensea, LLC dba “Blue Med Consultants”.