CONSENT TO TREAT: I hereby consent to examination and treatment by my health care provider at the office of Do Well Medical Center. I understand that my healthcare provider may access medical information about my medication use from electronic prescribing software and databases. I understand that there are potential risks with medications prescribed, and benefits from any treatment cannot be guaranteed. I hereby affirm that I am of legal age and otherwise competent to consent to medical treatment. If not, the person signing below represents that such person as the parent, legal guardian or person otherwise allowed by law to consent to the examination and treatment of the patient and by their signature hereby consents.
AUTHORIZATION AND ASSIGNMENT OF BENEFITS: I hereby authorize the office of Do Well Medical Center to bill my insurance for covered services rendered and to release any information that may be required to secure payment for charges incurred by me or on my behalf. I authorize payment directly to my provider of any insurance benefits otherwise payable to me and in the event I receive payment from my insurance carrier, I agree to endorse any payment I receive over to Do Well Medical Center. I also authorize the release of any information to county, state, or federal public health agencies, as required by law.
TELEHEALTH: I understand that there are risks, benefits, and consequences associated with telehealth, including disruption due to technology failures, breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. I agree that certain situations, including emergencies and crises, are inappropriate for telehealth services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care provider/facility in my area. I agree to inform my provider of the address where I am located at the beginning of each session in case an emergency occurs during that session. I also agree not to record any telehealth sessions without written consent from my provider and understand that my provider will not record any sessions without my written consent.
TEXT and EMAIL NOTIFICATIONS: I hereby consent to receive texts and/or emails for the following notifications: appointment reminders, appointment confirmations, patient campaigns & marketing, patient surveys, telehealth links/notifications, online statements, portal notifications, and other relevant information.
Administrative and Financial: If you have insurance, we will make every effort to assist you with your carrier to make sure your treatment is authorized, and reimbursement Is received. However, our professional services are rendered to you, not the insurance company. Therefore, payment for services is ultimately your responsibility. ALL CO-PAYMENTS ARE DUE AT THE TIME OF THE VISIT. Applicable deductibles may be required at the time of the visit or may be billed to you after insurance has processed. Unpaid balances over 90 days old will be turned over to a collection agency and you will be discharged from the practice.
Our office must be notified of any insurance changes PRIOR to your next appointment so that we can verify eligibility and benefits. If you do not inform us of any changes, you will be responsible for any charges not covered by your insurance company. There is a $50 fee for all returned checks. Returned checks are not re-deposited and if not paid may be turned over to the State Attorney’s office.
Appointments: As a courtesy to our patients, we offer an appointment reminder service. However, if for any reason our office fails to contact you, you are still responsible for keeping the appointment. If you arrive late for your appointment, there is no guarantee that you will be seen. Accommodation will be at the provider’s discretion.
Late Cancels/No-Shows: Please provide 24-hours’ notice to cancel appointments. Each time a patient misses an appointment without providing proper notice, another person is prevented from receiving care. Your time is very valued, and we will always do our best to have you scheduled on short notice with cancellation slots when needed if they become available. We appreciate the opportunity to do that for others as well. Late cancellations/no-shows will be assessed a fee equal to the self-pay rate for the scheduled service; waiver of this fee may be made if we are able to fill the spot with another client; otherwise, waivers will be at your provider’s discretion only. Multiple no-shows and/or late cancellations may result in discharge.
Prescriptions and Medications: The patient (or parent/guardian) must contact the office for all refill requests. Call 904-914-8947 or send an email to admin@dowellmedical.org WE DO NOT ACCEPT REFILL REQUESTS FROM PHARMACIES. Please ask the pharmacy to take your prescriptions off their auto-refill system. Refill requests can take up to three (3) business days to process and there are no guarantees that urgent demands for refills will be met within this 3-day window.
Treatment and Continuity of Care: To ensure adequate medical oversight and in accordance with accepted standards of care, follow-up appointments will be every 3-4 months unless otherwise determined by your provider based on clinical acuity. For mental health, if you have not been seen in over 12 months for medication management, or in over 3 months for therapy, your chart may be closed, and a return to care would be at the discretion of, and upon approval from, the rendering provider. Non-compliance with your provider’s treatment plan and/or recommendations, including multiple missed appointments, will result in discharge from the practice.
A parent or guardian MUST be present at the time of any minor child’s medication management appointment. Medication changes cannot be made without parental consent.
Messages, Emergencies, and After-Hours Calls: Always remember: if you have a potentially life-threatening emergency and/or need help immediately, call 911 or go to the nearest emergency room. You may also dial/call 211 for United Way’s crisis hotline or 988 for the National Suicide Prevention Lifeline. If you have non-emergent concerns after hours, you can leave a message or send an email to admin@dowellmedical.org. Messages and emails will be checked the next business day. On workdays, when the office is open, messages and emails are checked frequently throughout the day.
Providers return calls according to clinical acuity and usually at the end of the day. Please be aware that if your concern is complex orrequires lengthy discussion you may be asked to schedule an office appointment or be billed for a non-visit phone consult. Phoneconsults are not covered by insurance. If your provider, or employee, calls you from their personal cell phone, and you are able toobtain the phone number, DO NOT use that number for any reason. We ask that you always contact the office with appointment andrefill requests or clinical concerns. Please do not email the providers directly.We will update our website (www.dowellmedical.org) and Social Media pages with any unscheduled office closures
I hereby attest that I have read and understood the information provided to me regarding the Office Policies, and I agree to abide by these terms and conditions. I understand that if the above policies are not adhered to, the providers at Do Well Medical Center will not be able to provide my care and I may be discharged from the practice.
