Ascend Medical
Universal Combined Consent
This
consent is intended for all patients receiving care from Ascend Medical and
should be completed prior to the first visit.
1. Patient Privacy
(HIPAA /Treatment, Payment & Operations)
Acknowledgment of receipt of Ascend
Medical's Notice of Privacy Practices, which describes how protected health
information may be used and disclosed for treatment, payment, and healthcare
operations and explains the patient's privacy rights.
2. Consent for
Treatment
I
authorize Ascend Medical and its providers to evaluate, diagnose, and treat my
medical and behavioral health conditions, including counseling and therapy when
clinically appropriate, prescribe medications, order medically appropriate
tests and referrals, coordinate my care with other healthcare providers, and
provide healthcare services through telemedicine, including secure audio,
video, or other electronic communications, as permitted by applicable law and
payer requirements. I understand that I may decline telemedicine services when
an in-person visit is reasonably available and clinically appropriate. I
understand that no guarantees or assurances have been made regarding the
results or outcome of my care.
3. Behavioral Health
Privacy & Confidentiality
If I receive behavioral health services,
I understand that these services are generally confidential. Information may be
disclosed when required or permitted by law, including in cases of suspected
abuse or neglect, imminent risk of serious harm, or other legal requirements.
4. Medication
History & Health Information Exchange
Authorization
to obtain medication history from pharmacies, payers, Surescripts, and other
providers and to participate in applicable Health Information Exchanges.
5. Assignment of
Benefits
I
authorize Ascend Medical to release information necessary to process claims,
submit claims on my behalf, assign insurance benefits directly to Ascend
Medical, and communicate with my health plan and other payers regarding payment
for services provided to me. For Medicare beneficiaries, this authorization
will remain in effect for future claims until revoked in writing or otherwise
terminated in accordance with applicable law and payer requirements.
6. Financial
Responsibility Agreement
I authorize Ascend Medical to release
information necessary to process claims, submit claims on my behalf, assign
insurance benefits directly to Ascend Medical, and communicate with my health
plan and other payers regarding payment for services provided to me. For
Medicare beneficiaries, I understand that this authorization will remain in
effect for future claims until I revoke it in writing or it is otherwise
terminated in accordance with applicable law and payer requirements.
7. Card on File
Authorization
Authorization
for Ascend Medical and its payment processor to securely store a payment card
and charge patient-responsible balances in accordance with clinic policy.
Patients may revoke this authorization subject to alternate payment
arrangements before future services.
8.
Cancellation and No-Show Policy
I
understand that Ascend Medical requires advance notice to cancel or reschedule
an appointment. Late cancellations or missed appointments may result in a fee,
which may vary by service and will be communicated in advance. These fees may
not be covered by insurance and are my responsibility. Ascend Medical may waive
fees in cases of emergency or other extenuating circumstances.
9.
Electronic Communications
I
authorize Ascend Medical to communicate with me regarding my healthcare and
related administrative matters by telephone, voicemail, text message, email,
and the patient portal using the contact information I provide. I understand
that standard messaging rates may apply, and that electronic communications may
not be completely secure.
Ascend Medical Longitudinal
Care Consent
About This Consent
This
consent authorizes Ascend Medical to provide additional ongoing clinical
services, when clinically appropriate, to support your care between office
visits. These services are intended to help monitor your health, support your
treatment plan, and improve your long-term health outcomes. Participation is
voluntary.
Participation
in these services is voluntary.
Consent for Longitudinal
Care Programs
By
signing below, I authorize Ascend Medical and members of my care team to
provide additional ongoing clinical services when clinically appropriate to
support my care in between office visits.
Examples
of these services may include ongoing assessment, monitoring, care planning,
education, coaching, behavioral health support, cognitive assessment,
technology-assisted services, remote monitoring, follow-up after emergency
department visits or hospitalizations, and other clinically appropriate
services recommended by my care team.
Services
may be provided in person, by telephone, through telemedicine, through remote
monitoring technologies or other digital health tools, or through other
communication methods permitted by applicable law and payer requirements.
I
understand that participation is voluntary and that I may withdraw this consent
at any time by notifying Ascend Medical. I understand that Ascend Medical may
bill my health plan (whether Medicare or another third-party payers) for
covered longitudinal care services in accordance with applicable payer
requirements and that deductibles, copayments, or coinsurance may apply. I also
understand that certain ongoing care services may only be billed by one
provider during a given period, and I agree to notify Ascend Medical if I am
receiving substantially similar services from another provider.
Patient
Acknowledgement
By
signing below, I acknowledge that I have read (or had read to me), understand,
and voluntarily authorize Ascend Medical to provide the additional ongoing
clinical services described above. I have had the opportunity to ask questions
and understand that I may withdraw my consent at any time by notifying Ascend
Medical. If I am signing on behalf of the patient, I certify that I have the
legal authority to do so.