Medical Consent Form

We are looking forward to providing you with high quality care for your visit. Thank you for trusting us with your care. Please review the following information.   The above named patient hereby authorizes and consents to any services, including but not limited to diagnostic, radiology and/or laboratory procedures which are deemed necessary or advisable by the provider (physician, physician assistant, or nurse practitioner) and rendered to the patient under the general or special instructions of said provider(s).   I hereby authorize consent for the treating provider to gain access to medical records which would be relevant to diagnosis and treatment. I also authorize Rume Health and Rume Medical Group and my provider to release any medical information required in the processing of applications for financial coverage for services provided.   I understand that the physician, and/or nurse practitioner and/or physician assistant will explain my condition(s), foreseeable risks, and methods of treatment for the known condition(s) before treatment is provided.   I authorize The Practice, its’ subsidiaries and practitioners to perform any additional or different treatment(s) that is(are) necessary as deemed by the professional opinion of the Dr., NP or PA. Should a condition be discovered which was not known previously, I certify that I can be reached at the telephone # listed above in case of emergency, emergent test results, and/or further care is deemed necessary.   I authorize the release of my medical records, or in case of a minor, my child’s medical records, to my primary care physician. This and any other subsequent authorizations to release Protected Health Information comply with the Privacy Practices Notice and Federal HIPAA regulations. I have been provided, or offered and declined, a copy of the Notice of Privacy Practices and Patient Financial Policies.  
Patient Financial Policy
I understand that if I do not pay as services are rendered, a service charge may be added each month, if there is an outstanding balance. Should this account become delinquent, I understand that I am responsible for any and all legal fees, court costs, and collection fees involved as a result of any collection activity.   I hereby authorize Rume Health and Rume Medical Group Urgent Care to treat and furnish information to insurance carriers concerning the diagnosis and treatment of the patient listed above. I understand that I am responsible for all charges, regardless of insurance coverage. I also understand that payment (co-pays, deductibles, etc) is due at time of service.   I understand that charges are NOT final until the chart has been reviewed and the billing process is completed. In the event that the final balance on the account or invoice is a credit, the Practice has 30 days to notify the policyholder, guarantor or other responsible party by US Mail that a credit balance is on the account. In the event of no response to the notification, I authorize the credit to remain on my account and applied to any future services.  
Assignment of Benefits
I authorize my insurance company to pay benefits directly to Rume Health Inc.. I have read, understand, and agree to the Rume Medical Group (The Practice) Patient Financial Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility. In the event of my default, or non-payment of my bill, I agree to pay all collection costs, reasonable attorney’s fees and court costs that may be added to the account as collection costs, in addition to the amount due for services rendered.  
Marketing/Communication Agreement
I authorize Rume Health, to send e-mails to my e-mail address indicated above for business purposes such as surveys, announcements, events, articles, links, general medical information and marketing material.   I authorize my insurance company to pay benefits directly to Rume Health Inc.. I have read, understand, and agree to the Rume Medical Group (The Practice) Patient Financial Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility. In the event of my default, or non-payment of my bill, I agree to pay all collection costs, reasonable attorney’s fees and court costs that may be added to the account as collection costs, in addition to the amount due for services rendered.   I understand that I can opt out of the e-mail program at any time by following the instructions to ‘opt out’. X I hereby give my consent and authorization to The Practice, its’ subsidiaries and its’ practitioners to provide my medical treatment. If the patient is a minor, I, as custodian of the child, give my consent and authorization to The Practice, its’ subsidiaries and its’ practitioners to provide treatment for the minor patient.  
Notice of Privacy Practices
I hereby authorize Rume Health and Rume Medical Group, and their healthcare providers to release all information necessary to my insurance company both when requested, or to facilitate the payment of my claim(s).   I further agree that a photocopy of this agreement shall be as valid as the original. As the person bringing the patient in, (the parent, the guardian and/or the custodian of the patient, or a person as allowed by Law), I agree to be responsible for all services rendered to minor patients.   I hold The Practice harmless for attempts to collect regardless of parental, guardian or custodial financial responsibility. I agree to be responsible for payment regardless of any divorce, separation or other outside agreements that may or may not be in effect at the time of service.   I have read The Practice Policies above regarding: Authorizations, Consents, Medical Records, Billing, Refunds, Guardian, Assignment of Benefits, Message, and email Marketing. I have read, understand and have been offered a copy of the posted Notice of Privacy Practices, the practice policies: ‘Patient Financial Policy’, ‘Notice of Privacy Practices’ and the ‘Notice to Patients Regarding Credit Balance and Refunds’ policies. I certify the information provided is true, correct and accurate.  

Medical Consent Form

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We are looking forward to providing you with high quality care for your visit. Thank you for trusting us with your care. Please review the following information.   The above named patient hereby authorizes and consents to any services, including but not limited to diagnostic, radiology and/or laboratory procedures which are deemed necessary or advisable by the provider (physician, physician assistant, or nurse practitioner) and rendered to the patient under the general or special instructions of said provider(s).   I hereby authorize consent for the treating provider to gain access to medical records which would be relevant to diagnosis and treatment. I also authorize Rume Health and Rume Medical Group and my provider to release any medical information required in the processing of applications for financial coverage for services provided.   I understand that the physician, and/or nurse practitioner and/or physician assistant will explain my condition(s), foreseeable risks, and methods of treatment for the known condition(s) before treatment is provided.   I authorize The Practice, its’ subsidiaries and practitioners to perform any additional or different treatment(s) that is(are) necessary as deemed by the professional opinion of the Dr., NP or PA. Should a condition be discovered which was not known previously, I certify that I can be reached at the telephone # listed above in case of emergency, emergent test results, and/or further care is deemed necessary.   I authorize the release of my medical records, or in case of a minor, my child’s medical records, to my primary care physician. This and any other subsequent authorizations to release Protected Health Information comply with the Privacy Practices Notice and Federal HIPAA regulations. I have been provided, or offered and declined, a copy of the Notice of Privacy Practices and Patient Financial Policies.  
Patient Financial Policy
I understand that if I do not pay as services are rendered, a service charge may be added each month, if there is an outstanding balance. Should this account become delinquent, I understand that I am responsible for any and all legal fees, court costs, and collection fees involved as a result of any collection activity.   I hereby authorize Rume Health and Rume Medical Group Urgent Care to treat and furnish information to insurance carriers concerning the diagnosis and treatment of the patient listed above. I understand that I am responsible for all charges, regardless of insurance coverage. I also understand that payment (co-pays, deductibles, etc) is due at time of service.   I understand that charges are NOT final until the chart has been reviewed and the billing process is completed. In the event that the final balance on the account or invoice is a credit, the Practice has 30 days to notify the policyholder, guarantor or other responsible party by US Mail that a credit balance is on the account. In the event of no response to the notification, I authorize the credit to remain on my account and applied to any future services.  
Assignment of Benefits
I authorize my insurance company to pay benefits directly to Rume Health Inc.. I have read, understand, and agree to the Rume Medical Group (The Practice) Patient Financial Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility. In the event of my default, or non-payment of my bill, I agree to pay all collection costs, reasonable attorney’s fees and court costs that may be added to the account as collection costs, in addition to the amount due for services rendered.  
Marketing/Communication Agreement
I authorize Rume Health, to send e-mails to my e-mail address indicated above for business purposes such as surveys, announcements, events, articles, links, general medical information and marketing material.   I authorize my insurance company to pay benefits directly to Rume Health Inc.. I have read, understand, and agree to the Rume Medical Group (The Practice) Patient Financial Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility. In the event of my default, or non-payment of my bill, I agree to pay all collection costs, reasonable attorney’s fees and court costs that may be added to the account as collection costs, in addition to the amount due for services rendered.   I understand that I can opt out of the e-mail program at any time by following the instructions to ‘opt out’. X I hereby give my consent and authorization to The Practice, its’ subsidiaries and its’ practitioners to provide my medical treatment. If the patient is a minor, I, as custodian of the child, give my consent and authorization to The Practice, its’ subsidiaries and its’ practitioners to provide treatment for the minor patient.  
Notice of Privacy Practices
I hereby authorize Rume Health and Rume Medical Group, and their healthcare providers to release all information necessary to my insurance company both when requested, or to facilitate the payment of my claim(s).   I further agree that a photocopy of this agreement shall be as valid as the original. As the person bringing the patient in, (the parent, the guardian and/or the custodian of the patient, or a person as allowed by Law), I agree to be responsible for all services rendered to minor patients.   I hold The Practice harmless for attempts to collect regardless of parental, guardian or custodial financial responsibility. I agree to be responsible for payment regardless of any divorce, separation or other outside agreements that may or may not be in effect at the time of service.   I have read The Practice Policies above regarding: Authorizations, Consents, Medical Records, Billing, Refunds, Guardian, Assignment of Benefits, Message, and email Marketing. I have read, understand and have been offered a copy of the posted Notice of Privacy Practices, the practice policies: ‘Patient Financial Policy’, ‘Notice of Privacy Practices’ and the ‘Notice to Patients Regarding Credit Balance and Refunds’ policies. I certify the information provided is true, correct and accurate.  
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