Consent for Medical Treatment

I (as patient, parent, guardian, spouse, guarantor, or other responsible party) consent to and authorize medical treatment and diagnostic procedures which may be ordered and/or provided by my doctor and performed at Medical University Hospital Authority, its ambulatory locations (“MUHA”), University Medical Associates of the Medical University of South Carolina locations (“MUSC Physicians”), and Carolina Family Care, Inc. (“Carolina Family Care”). MUHA, MUSC Physicians, and Carolina Family Care are collectively referred to as “MUSC Health” in this document. I consent to have blood drawn and to be tested for infectious diseases, including but not limited to syphilis, AIDS, hepatitis and testing for drugs if my doctor orders these tests.

Consent for Medical Treatment Delivered via Telehealth

By initialing here, I further give my consent to receive medical treatment from MUSC Health via telehealth modalities (e.g. tools which provide for remote audio and/or visual interaction between the patient and the healthcare provider) and/or remote patient monitoring (RPM) tools (collectively, “Telehealth”). The Telehealth service will be provided in a confidential manner and information will not be released without proper consent. I authorize physicians or designated health professionals to provide necessary and/or advisable treatment via Telehealth. I also understand that other individuals may be present to operate the video equipment and that they will take the reasonable steps to maintain confidentiality of the information obtained. I understand that I have the right to ask my healthcare provider to discontinue the Telehealth encounter at any time. I understand there are potential risks associated with this technology including that the video connection may stop working during the encounter, the video picture or information transmitted may not be clear enough to be useful for the encounter, and I may be asked to go to the location of the consulting physician if it is determined that the information obtained via Telehealth was not sufficient to make a diagnosis.

Photographs/ Video Usage

I agree that my photograph and/or video may be taken to identify me or provide treatment to me. Such photographs and videos may become part of my medical record. Photographs and videos will be used in a manner that promote patient safety, privacy, dignity and confidentiality. Photographs and videos are not recorded for research or educational purposes. I agree and consent to such photography and/or video usage.

Consent to Telephone Calls and/or Text Messages

I consent to MUSC Health, its employees, agents, collections agents, service providers and the like, to contact me by telephone at any telephone number that I or my representative provides to MUSC Health. This includes voice calls and/or text messages to the wireless telephone numbers or other numbers. This may result in data us age and other charges to me. These calls may be appointment reminders or about my bills. MUSC Health will only send general information and nothing confidential. I may choose to not receive text messages from MUSC Health by the opt-out message sent with each text.

Agreement of Financial Responsibility and Assignment of Insurance Benefits

The hospital and attending physician are authorized to release any medical information required in the processing of applications or submission of information for financial coverage, including information referring to psychiatric care, drug and alcohol abuse, sexual assault, or tests for infectious diseases including AIDS/HIV for services provided during this admission. I / we also agree to the release of medical or other information about to government regulatory agencies (federal or state) as required by law. For Medicare / Medicaid beneficiaries – I / we have provided all necessary information for proper assignment of Medicare / Medicaid benefits. In return for the services rendered and to be rendered by MUSC Health, I hereby guarantee the payment of all charges associated with services received from MUSC Health. I hereby irrevocably assign and transfer to MUSC Health all right, title, and interest in all benefits payable for the healthcare rendered, which are provided in any and all insurance policies and health benefit plans from which I am entitled to recover, including but not limited to hospitalization, medical, third party liability insurance coverage, workers compensation benefits, employer, employer group, individual, welfare benefit, trust sponsored, and benefits paid by Medicare or Medicaid. This assignment is intended to include any interest in benefits that I may have relating to this date of service as well as any prior dates of service.

By executing this assignment of benefits, I am requesting that all insurance companies pay MUSC Health directly for the services MUSC Health provided to the patient. I understand that any payment received from these policies and/or plans will be applied to any outstanding balance that I may have with MUSC Health. I further understand that I am not entitled to a refund unless all MUSC Health bills are paid in full for any outstanding balances owed to them. If a third party may be obligated to pay some or all of these charges, I agree to take all actions necessary to assist MUSC Health in collecting payment from any such third party payer. I hereby appoint MUSC Health as my authorized representative to pursue, if it so chooses, all administrative remedies, claims, appeals, and/or lawsuits on my behalf and at MUSC Health's election, against any responsible third party, medical insurer, or employer sponsored medical benefit plan for purposes of collecting any and all hospital benefits due me for the payment of the charges. I authorize MUSC Health to endorse and retain benefit checks made payable directly to me.

I understand that MUSC Health may bill an insurance company, as a courtesy to me, but may not be obligated to do so. I understand if MUSC Health initially accept health insurance coverage, this does not waive their rights to collect or accept, as payment in full, any payment made under a different coverage or benefits or any other sources of payment that may or will cover expenses incurred for services and treatment. I understand that Professional Services may be rendered by independent contractors, and are not part of MUSC Health bills. I understand that care that is experimental as determined by my insurance company may not be covered and that I will be responsible for those charges. I agree that if my account is not paid, it may be turned over to a collection agency or attorney, and I must pay the amount due plus all costs of collection, including reasonable attorney’s fees and costs.

I understand that if I am unable to pay my bills, I may speak with a Financial Counselor to determine whether I qualify for assistance. The telephone number for the Financial Counselor of MUSC Health is (843) 792-2311. I have read and been given the opportunity to ask questions about this assignment of benefits, and I have signed this document freely and without inducement, other than the rendition of services by MUSC Health.

What this means:

• I agree for MUSC Health to release my personal health information to my insurance company or anygovernment agencies as required by law.
• I agree that I am responsible for all charges and request all insurance companies pay MUSC Healthdirectly.
• Any payments from my insurance company may be applied to any outstanding balance.
• I understand I may not be entitled to a refund unless any past due MUSC Health bills are paid in full.
• MUSC Health may bill an insurance company as a courtesy to me but is not obligated to do so.
• I understand my insurance company determines what they pay for and it is not the responsibility ofMUSC Health to make this determination.
• I agree that if my account is not paid, it may be turned over to a collection agency or attorney, and I mustpay the amount due plus all costs of collection.

Medicare Patient Certification (Medicare patients only)

I hereby certify that I have provided information about all insurance coverage available to me, including liability or worker’s compensation insurance, and that the information provided is correct and complete. I hereby authorize MUSC Health to release to the Social Security Administration, its intermediaries, or carriers any information needed for this or a related Medicare claim. I hereby authorize the payment of benefits to MUSC Health.

Agreement of Financial Responsibility for Non-Covered Services (Not applicable for all patients)

By signing and dating this form, I am indicating that I have been informed by MUSC Health or other related organization that the services the patient will receive today may not be covered because of the reason indicated below (Patient to initial the appropriate section if applicable).
MUSC Health / the rendering physician is not a contracted / credentialed provider for your health plan You will be responsible for any amounts not covered by your insurance plan.
Your insurance carrier / primary care physician has not provided a referral / authorization for today’s service. You will be responsible for any amounts not covered by your insurance plan.
Your condition may be considered pre-existing based on the length of your coverage under your insurance plan.
Your service may not be considered medically necessary by your insurance plan. You may be responsible for the entire cost of the service.
Other reason

Guidelines for Release of Information Specific to Alcohol and Substance Programs

The release of information to anyone regarding a patient involved in the alcohol and drug programs at the MUSC Health is governed by strict Federal Confidentiality Laws. Federal Regulations (42 CFR Part 2) prohibit MUSC Health from making any disclosure of any information without the written consent of the person to whom information pertains. Federal Laws and regulations do not protect information regarding a crime or a threat to commit a crime or any information regarding suspected abuse or neglect from being reported to appropriate State or Local authorities. Disclosures made without patient consent which includes patient identification are as follows: 1) internal program communications, 2) medical personnel in medical emergencies, and 3) disclosures pursuant to valid court orders. Disclosures made for research or audit purposes and other requests that contain no patient identification information, may be released without patient consent. Other than those listed above, MUSC Health may not disclose information to anyone unless a separate consent form is filled out and signed by the individual to which the information pertains, authorizing MUSC Health to release specific information to specific individuals(s) / agency(ies). I understand that failure to consent to disclosure to third party payers and funding sources will result in personal financial incumbency.

HIPAA (Health Insurance Portability and Accountability Act) Disclosure/ Use of Health Information Notification

The MUSC Organized Health Care Arrangement’s (OHCA) Notice of Privacy Practices can be found here (https://web.musc.edu/about/compliance/privacy). I certify that I have reviewed and/or received a copy of the MUSC OHCA “Notice of Privacy Practices.” I understand that uses and disclosures of my personal health information are described in the Notice of Privacy Practices received. Possible disclosures include, but are not limited to, disclosure to another health care provider or Health Information Exchanges (HIE) for treatment, process of payment, or MUSC OHCA operations. See attached Notice of Privacy Practices for additional possible disclosures and instructions on how to limit my participation in HIE or to whom my health information is disclosed.

I understand that this consent for medical treatment, assignment of insurance benefits and agreement of financial responsibility will be valid for one year from the date of signature and can only be revoked upon written notice.

I understand that the authorization for release of information, which is a separate form I will complete, will be valid for one year from the date of acceptance and can only be modified or revoked upon written notice. I certify that I have read or have had read to me this consent and agree to its terms. I also certify that I am the patient, or am duly authorized by the patient, or am duly appointed to sign this agreement. I accept and understand its terms.

I received a copy of the MUSC “Notice of Privacy Practices”.
I hereby consent to participate in a Telehealth Service visit under the conditions described in this document.