Coastal Mobile Medical Care
CONSENT TO MEDICAL CARE AND FINANCIAL RESPONSIBILITY
CONSENT TO MEDICAL CARE. I hereby authorize the medical providers (“Physician Assistant or Nurse Practitioner or Provider(s)”) of Coastal Mobile Medical Care, LLC (the “Practice”), and their staff, to perform any medical diagnostic procedures and medical care which in their professional judgment is deemed necessary to diagnose and/or treat the conditions that have brought about my seeking medical care services from the Practice. I voluntarily consent to medical care and treatment by the Practice, and its affiliated providers, including but not limited to diagnostic and laboratory tests and procedures; administration of pharmaceuticals or anesthesia; and such other care as deemed reasonably necessary or advisable by the providers. I understand that no treatments, other than treatments needed to address a medical emergency, will be permitted unless I, or a person legally authorized to consent on my behalf, has consented to the treatment. I also understand that I have the right to give, withhold or revoke my consent for any medical treatment at any time. I acknowledge that no guarantees are made to me concerning the outcomes of the treatment rendered by the health care providers of the Practice.
- I understand that the Services (the“Service(s)”) the Practice provides include urgent medical care services, including but not limited to laceration repair, incision and drainage; IV therapy; COVID-19 testing, RSV testing, influenza testing and strep testing. I agree that the Practice has discussed the proposed care, treatment, and services with me as well as communicated to me the risks and benefits associated with the proposed Services that I am agreeing to undertake, and I have had an opportunity to ask the practitioner any questions I have on the risk associated with the Services I am undertaking. Knowing each of those risks, I am agreeing to be proceed with the Services from the Practice.
- I acknowledge and agree to the rendering of Services by the staff of the Practice, including the medical doctor, nurse practitioner, physician assistant, nurse, or other staff person. Services may include, but are not limited to, obtaining a medical history, performing a physical examination or telemedicine examination, and providing treatments or care as needed.
- I understand that I am assuming the risk of exposure to COVID-19 (or other public health risk) by having these Services provided. Moreover, by inviting the Practice into my home or workplace, I understand that there may be an increase in risk to exposure to other individuals who I am in contact with. I agree to inform the Practice if either myself or anyone I live with or anyone I have been in contact with displays any symptoms consistent with the coronavirus.
- I understand that the Practice may create a customized therapy to meet my needs. I understand that such custom therapies may not be reviewed or approved by the Food and Drug Administration or any other entity for safety, quality, or effectiveness. I knowingly and voluntarily consent to such therapies regardless of whether or not they are approved by the FDA or any other entity for safety, quality, or effectiveness.
CONSENT TO TELEMEDICINE. I consent to receiving a medical screening via telehealth/telemedicine methods and understand that there are certain risks associated with receiving care through telehealth/telemedicine methods. Furthermore, I have made the medical staff aware of all my known health conditions, allergies, and medications I am taking.
- Though every effort is made to ensure confidentiality, the limitations and risks in telehealth/telemedicine include public discovery, possibility of hackers, disruption by technical failures, household noise or interruptions, risks of being overheard by persons near me, and other potential risks outside of the Practice’s control. I understand that I am responsible for using a location that is private and free from distractions or intrusions.
- Even with using best practices with telehealth/telemedicine services, any information transmitted via the internet may not be 100% secure.
- I also understand that miscommunication between myself and the practitioner may occur via telehealth or telemedicine services. Furthermore, I understand and acknowledge that, in some instances, telehealth and telemedicine services may not be as effective or provide the same results as in-person care or Services.
- I understand that while telehealth/telemedicine services have been found to be effective in treating a wide range of issues, there is no guarantee that telehealth/telemedicine is effective for all individuals. Therefore, I understand that while I may benefit from telehealth/telemedicine, results cannot be guaranteed or assured.
FINANCIAL AGREEMENT AND GUARANTEE. I understand that neither the Practice, nor its providers participate in any federal or state government health programs or private health insurance plans, including Medicare. All services provided to me by the Practice are self-pay services, meaning I am solely responsible for paying the Practice for any of the services provided to me. The Practice does not make any representations regarding third-party insurance coverage or reimbursement and such reimbursement is not anticipated under this CONSENT TO MEDICAL CARE AND FINANCIAL RESPONSIBILITY (this “Agreement”).
By signing this Agreement, I hereby acknowledge that I accept full and complete financial responsibility for all medical services rendered to me and agree to pay for the services in full prior to receiving testing. I hereby authorize the Practice to charge to the credit card or debit card provided by me for the cost of all services furnished by the Practice to me. I further acknowledge, understand, and agree that in the event that I fail to make such payments in accordance with the payment policies of the Practice, or in the event of default of my financial obligation to pay for services rendered, the Practice may terminate the “provider-patient” relationship with me. Furthermore, I agree to pay all costs of collection, reasonable attorneys’ fees and court costs incurred in enforcing this payment obligation.
- Medicare Acknowledgment. The Practice and its providers do not participate in the Medicare program. This means that Medicare cannot be billed for any services provided to you by the Practice. By signing this Agreement, if you are a Medicare beneficiary, you agree not to bill Medicare or attempt Medicare reimbursement for any services provided to you by the Practice or any of its providers. If you are eligible for Medicare, or you become eligible for Medicare, then the Practice is required to obtain your understanding, memorialized by your signature, of our Private Medicare Contract. If you are (or become) Medicare eligible and choose not to sign our Private Medicare Contract, you agree and acknowledge that the Practice and its providers cannot provide you with any further services.
MEDIATION AND ARBITRATION AGREEMENT. While the Practice does not anticipate any issues or concerns during the course of my treatment, it is understood and agreed by me and the Practice as well as its employees (including, any nurses, physicians, etc.), agents, contractors, subsidiaries, affiliates, successors or assigns, that any and all disputes between us exceeding the jurisdictional limit of the small claims court, including, but not limited to any claim of medical malpractice, loss of consortium, wrongful death, and emotional distress (“Dispute(s)”) shall first be submitted to non-binding mediation or, if such mediation proves to be unsuccessful, to binding arbitration, and not by a lawsuit or resort to court process except as applicable law provides for judicial review of arbitration proceedings. A Dispute shall be waived and forever barred if (i) on the date notice thereof is received by a party requesting Mediation and/or arbitration of a Dispute, the claim, cause of action or Dispute, if asserted in a civil action, would be barred by the applicable statute of limitations for the applicable state or federal law that would otherwise govern it if it had been brought in civil court, or (2) the applicable party fails to pursue arbitration in accordance with the procedures prescribed herein with reasonable diligence. It is our intent that this agreement binds all parties whose claims may arise out of or related to any treatment or service provided by the Practice to me, including my spouse (if any) or heirs and any children, whether born or unborn, at the time of the occurrence giving rise to any claim.
All Disputes based upon the same incident, transaction or related circumstances shall be mediated and, if necessary, arbitrated in one proceeding. However, I agree that the Practice may, at the Practice’s sole discretion and in lieu of mediation or arbitration, file one or more actions in a court of appropriate jurisdiction to collect any fees owed by me to the Practice. The filing by the Practice to collect any fees from me shall not waive the Practice’s right to compel mediation and arbitration of any other Disputes.
- Mediation. Prior to either of us pursing any Disputes either in arbitration or otherwise, we will voluntarily submit all Disputes (except to pursue injunctive relief) to voluntary non-binding mediation before a jointly selected neutral third-party mediator (“Mediation”). Mediation shall occur in Jacksonville, Florida within sixty (60) days of either of us notifying the other party in writing of such dispute. The mediator’s fee shall be split equally between us; however, each of us shall pay the fees of our own attorneys and expenses of our own witnesses (if any).
- Arbitration. All Disputes that are not resolved by Mediation shall be resolved by final and binding arbitration except for Disputes that are expressly prohibited by applicable law from being subject to binding arbitration. Arbitration shall be conducted by a single neutral arbitrator in Jacksonville, Florida, under the auspices of the American Arbitration Association, in accordance with its current Expedited Rules and Procedures for Commercial Arbitration. Any award rendered pursuant to such arbitration shall be final and binding upon the parties, and judgment upon the award rendered by the arbitrator shall be entered in any court having jurisdiction over the parties. Each party shall bear its own costs and attorneys’ fees in connection with any such arbitration. However, the prevailing party in any arbitration shall be entitled to its reasonable attorneys’ fees, costs and necessary disbursements or expenses in addition to any other relief to which it may otherwise be entitled. Finally, we both agree that provisions of Florida law applicable to health care providers shall apply to disputes within this arbitration agreement
- I acknowledge and agree that I am executing this agreement to arbitrate andmediate voluntarily and without any duress or undue influence by the Practice or anyone else. I also warrant that I have not relied on any oral representations relative to mediation or arbitrations that is not in writing and included in this agreement. Furthermore, I acknowledge and agree that I fully understand this agreement, including that: BY AGREEING TO ARBITRATION, I AM GIVING UP AND WAIVING ANY RIGHTS THAT I MAY HAVE TO TRIAL BY A JUDGE OR JURY WITH REGARD TO THE MATTERS WHICH ARE REQUIRED TO BE SUBMITTED TO MANDATORY BINDING ARBITRATION, INCLUDING ANY MALPRACTICE DISPUTES. FURTHERMORE, I ALSO UNDERSTAND, ACKNOWLEDGE AND AGREE THAT THERE IS NO RIGHT TO APPEAL OR A REVIEW OF AN ARBITRATOR’S AWARD AS THERE WOULD BE A JUDGE OR JURY’S DECISION.
GOVERNING LAW. Except to the extent governed by the Federal Arbitration Act, this agreement shall be governed by, and construed and enforced in accordance with, the laws of the State of Florida and without regard to its conflicts of laws provisions. I hereby expressly consent to the personal jurisdiction of the state and federal courts located in Jacksonville, Florida, which shall have exclusive jurisdiction to adjudicate any dispute arising out of this agreement that is not otherwise governed by the arbitration provision herein.
SEVERABILITY. The invalidity or unenforceability of any particular provision of this agreement shall not affect the other provisions hereof, all of which shall remain enforceable in accordance with their terms. If any of the provisions of this agreement or any part of any of them is hereafter construed or adjudicated to be invalid or unenforceable, such provision (or portion thereof) will be enforced to the maximum extent permissible so as to effect our intent, and the remainder of this agreement will continue in full force and effect without regard to the invalid portions.
NO GUARANTEE. I understand and agree that the practice of medicine is not an exact science and that no guarantees have been made to me regarding the results of Patient’s care or treatment at PRACTICE.
PERSONS FOR WHOM PRACTICE IS NOT LIABLE. I understand that the Practice is only responsible for the acts of its employees acting within the scope and course of their duties. I understand that persons who are not employed by the Practice may be involved in my care or treatment, including but not limited to other practitioners, laboratories, diagnostic testing facilities, contractors, vendors, product technicians, etc. I understand that the Practice is not liable for the acts or omissions of non-employees or the Practice employees acting outside the course and scope of their duties.
I understand that the terms herein are contractual and not a mere recital; and that I sign this document as my own free act and void of any coercion. I also understand and acknowledge that I have the right to request and receive a copy of this agreement at any time from the Practice. The permissions granted herein shall begin on the date listed below and shall remain effective until terminated by the undersigned except for the financial agreement and guarantee, governing law, severability and mediation and arbitration sections herein, which cannot be terminated. My signature below verifies that I have read all of the information contained in this agreement and asked questions about anything I have not understood up to this point. I certify that I am either the patient or the patient’s legally authorized representative and have authority to execute this Consent to Medical Care and Financial Responsibility on behalf of the patient. I also represent by my signature below that the risks, benefits and alternatives of the recommended care, treatment(s), service(s), or procedure(s) have been explained to me and I approve and direct that the recommended care, treatment(s), service(s), or procedure(s) be performed.