CONSENT AND FINANCIAL AGREEMENT FOR PHYSICIAN CLINIC SERVICES

1. General Medical Consent

The undersigned consents to services that may be performed at the clinic, which may include but are not limited to laboratory procedures, X-ray examinations, treatment or procedures rendered the patient under general and special instructions of the patient's physician. The undersigned agrees to photographic documentation, production of recordings, films, or other images to assist in their treatment or for the clinic's operations, such as internal training activities and quality assurance review. The undersigned authorizes the clinic to dispose of, at its discretion any blood, body fluid, organ or other tissue removed or obtained during treatment. In addition to caring for patients, the clinic participates in educational affiliations to provide training to healthcare providers.

2. Financial Agreement

The undersigned agrees, whether he/she signs as agent or as patient, that in consideration of the service to be rendered to the patient, he/she hereby individually obligates himself/herself to pay the account of the clinic in accordance with the regular rates and terms of the clinic. Should the account be referred to an attorney or collection agency for collections, the undersigned shall pay actual attorney's fees and collection expenses. All delinquent accounts shall bear interest at the legal rate. By providing a telephone number to the hospital or your referring physician, you consent to receive auto dialed and prerecorded calls and text messages from the clinic, its vendors, and collection agencies relating to your account or relationship with the clinic, such as for treatment, billing, collections and eligibility for government healthcare programs. You may opt out of automated calls at any time by e-mail to patient.accounts@elcaminohealth.org.

3. Assignment of Insurance Benefits

The undersigned authorizes, whether he/she signs as agent or as patient, direct payment to the clinic of any insurance benefit otherwise payable to the undersigned for services rendered at a rate not to exceed the clinic's usual and customary charges. It is agreed that payment to the clinic, pursuant to this authorization, by an insurance company/Health Care Service Plan shall discharge that insurance company/healthcare service plan of any and all obligations under a policy to the extent of such payment. It is understood by the undersigned that he/she is financially responsible for charges not covered by this assignment.

4. Health Plan Obligation

It is the undersigned's responsibility to know and verify if benefits are covered in the insurance plan. The clinic maintains a list of health plans with which it contracts. A list of such plans is available upon request from the financial office. The clinic has no contract, express or implied, with any plan that does not appear on the list. The undersigned agrees that he/she is individually obligated to pay the full charges of all services rendered to him/her by the clinic if he/she belongs to a plan that does not appear on the above-mentioned list.

5. Open Payments Program

The Open Payment database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov

6. Preventive Services

By all health plans are covered under the Affordable Care Act (aka Obama Care) without copayment or coinsurance. The services covered are very specifically listed in the act and by the Health Plans. Most lab tests are not covered. If additional services are provided at a health maintenance visit (e.g. annual physical exam, well woman visit, routine checkup, etc.), an evaluation and management service may be charged which would require a copay or payment based on the patient's deductible. An additional service would include surveillance and management of a chronic condition or new medical complaint.

7. Appointment No-Show or Late Cancellation

The undersigned authorizes and acknowledges, whether he/she/they signs as agent or as patient, to submit direct payment to the clinic of any no-show or late cancellation fees as outlined by the "ECHMN No-show and Late Cancellation Fee Policy." It is the undersigned's responsibility to know and verify the pertinent details of aforementioned policy.

The undersigned certifies that he/she/they has read and understands this Consent and Financial Agreement, has received a copy of it, and is the patient or is duly authorized by or on behalf of the patient to execute and accept its terms.