Coastal Medical Care

 

CONSENT TO MEDICAL CARE AND FINANCIAL RESPONSIBILITY

CONSENT TO MEDICAL CARE.  I hereby authorize the health care providers (“Physician Assistant or Nurse Practitioner or Provider(s)”) of Coastal Mobile Medical Care, LLC (“Coastal”), 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 Coastal. I voluntarily consent to medical care and treatment by Coastal, 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 Coastal.

  1. I understand that the services (the “Service(s)”) Coastal provides are as set forth on Coastal’s Terms of Service. I have elected to receive the Service(s) set forth on Exhibit A. I agree that Coastal has discussed the proposed care, treatment, and Service(s) with me as well as communicated to me the risks and benefits associated with the proposed Service(s) 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 Service(s) I am undertaking. Knowing each of those risks, I am agreeing to be proceed with the Service(s) from Coastal.
  2. I acknowledge and agree to the rendering of Service(s) by the staff of Coastal, including the medical doctor, nurse practitioner, physician assistant, nurse, or other staff person. Service(s) 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.
  3. I understand that I am assuming the risk of exposure to COVID-19 (or other public health risk) by having these Service(s) provided. Moreover, by inviting Coastal 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 Coastal if either myself or anyone I live with or anyone I have been in contact with displays any symptoms consistent with the coronavirus.
  4. I understand that Coastal 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.

  1. 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 Coastal’s control. I understand that I am responsible for using a location that is private and free from distractions or intrusions.
  2. Even with using best practices with telehealth/telemedicine services, any information transmitted via the internet may not be 100% secure.
  3. 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.
  4. 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 all services provided to me by Coastal are self-pay services, meaning I am solely responsible for paying Coastal for any of the services provided to me. I hereby elect to pay cash for the Service(s) rather than utilize possible insurance benefits available to me pursuant to any third-party insurance coverage that I may have (“My Insurance Plan”).  By signing below, I hereby represent and warrant that I am not a Medicare beneficiary seeking covered services, and that I will not (nor will anyone on my behalf) submit any claims to Medicare for payment for Coastal’s Service(s).

By signing this Agreement, I hereby acknowledge and agree that:

  1. Neither Coastal nor I will file a claim with My Insurance Plan for the Service(s). I accept that I am personally responsible for the payment of the Service(s) rendered and that I must pay for such Service(s) in advance.
  2. No claim will be sent to My Insurance Plan since it is my personal decision not to use my health insurance benefits for the Service(s) even though I understand that the Service(s) may be considered covered by My Insurance Plan. I agree that I will not submit a claim with My Insurance Plan for the Service(s).
  3. By electing to self-pay for the Service(s), I understand that any payments I make to Coastal for the Service(s) provided by Coastal will not be credited toward satisfying any deductible of My Insurance Plan.

I hereby authorize Coastal to charge to the credit card or debit card provided by me for the cost of all services furnished by Coastal 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 Coastal, or in the event of default of my financial obligation to pay for services rendered, Coastal may terminate the “doctor-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.

GOVERNING LAW.  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.

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 Coastal.  

PERSONS FOR WHOM COASTAL IS NOT LIABLE.  I understand that Coastal 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 Coastal 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 Coastal is not liable for the acts or omissions of non-employees or Coastal employees acting outside the course and scope of their duties.

WAIVER OF JURY TRIAL.  I HEREBY KNOWINGLY, VOLUNTARILY AND INTENTIONALLY WAIVE ALL OF MY RIGHTS TO A TRIAL BY JURY IN ANY PROCEEDING BROUGHT TO ENFORCE OR DEFEND ANY TERMS OR PROVISIONS OF THIS CONSENT TO MEDICAL CARE AND FINANCIAL RESPONSIBILITY.

By signing below, I acknowledge that this Consent to Medical Care and Financial Responsibility is only valid for the on the date below for the Service(s) set forth on Exhibit A.  I further acknowledge that if I wish to have another date of service not be filed with My Insurance Plan or if I want any other Service(s) provided, that I will submit another Consent to Medical Care and Financial Responsibility.

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 Coastal.  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, and severability 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.

EXHIBIT A

Elected Services

I have elected to receive the following Service(s) from Coastal:

  • Office Visit. A personalized office visit with a medical provider.
  • Home Visit. A personalized home visit with a medical provider.
  • Telemedicine Visit. A personalized virtual visit with a medical provider.
  • IV Therapy. Vitamin IV infusions with a medical provider.
  • Wellness Visit. Vitamin injections, weight loss management, hormone replacement therapy with a medical provider.
  • Medication Administration. Oral, aerosolized, intramuscular and intravenous medication administration with a medical provider.
  • Testing. Including but not limited to COVID 19, RSV, influenza, and strep testing, and urinalysis by a medical provider.
  • Procedures. Including but not limited to IV placement, laceration management, suture or staple removal, incision and drainage, foreign body removal from eye, ear or nose, and fluorescein eye exam.