CONSENT FOR MEDICAL TREATMENT

The patient authorizes and consents to be treated by Duke City Primary care physicians and staff. The patient consents to any X-ray, examination, laboratory, procedures, anesthesia, minor surgical procedures or any medical services rendered under the general or specific instruction of the Duke City Primary Care physicians. The patient recognizes that some persons furnishing professional medical services, including but not limited to radiology and pathology, may be independent contractors and not employees or agents of the Clinic.

AUTHORIZATION & AGREEMENT BY PATIENT OR PATIENT GUARDIAN

All professional services rendered are charged to the patient. Necessary forms will be completed to expedite insurance payment. It is customary to pay for services when rendered unless arrangements are made in advance.

Duke City Primary Care is authorized to furnish information to insurance carriers concerning patient illnesses and treatments. Patient is responsible for payments to Duke City Primary Care for medical services rendered. Patient understands that they are fully responsible for any amounts not covered by patient’s insurance.

NO SHOW PENALTY FEE

If the patient does not call and cancel their scheduled appointment 24 hours prior to the appointment time and elects not to attend the appointment, they will be charged a $25.00 fee. If the patient is late for their appointment, the appointment may be cancelled and they will be rescheduled. This may result in a $25.00 fee.

AUTHORIZATION OF ASSIGNMENT OF BENEFITS & RELEASE OF INFORMATION AND CONSENT FOR TREATEMENT

Duke City Primary Care is authorized to directly collect payment for services rendered and supplies provided. This assignment is for all benefits otherwise payable to the patient, but not to exceed the indebtedness to said Clinic. Duke City Primary Care is authorized to release any information acquired in the course of treatment or examination. The patient is financially responsible for charges not covered by this assignment. The patient authorizes the release of any and all medical information necessary to process these claims and requests payment of any benefits due to the patient or for patient benefits to be made directly to Duke City Primary Care.

AGE OF CONSENT – WHERE MINORS ARE INVOLVED, THE FOLLOWING SHALL PREVAIL:

1. The consent of parent or legal guardian if patient is unmarried and has not yet attained the age of (18)
2. If a patient under the age of (18) years of age is married, or has been married and such marriage has been dissolved by dissolution or annulment, then the consent of a parent or guardian is not required.

CONSENT TO SMS COMMUNICATION

The patient hereby consents to the use of SMS text communication by Duke City Urgent Care for the purposes of appointment reservations, registration, and reminders; Lab result communication; General communication for healthcare concerns, issues and enquirers by Duke City Urgent Care staff. SMS communication is facilitated by the Duke City Urgent Care EHR & Clinical Automation Platform (Athena & Decoded Health). No SMS information will be shared with third parties/affiliates for marketing/promotional purposes. Please refer to our SMS Terms and Conditions Privacy Policy for further information.

SMS TERMS AND CONDITIONS PRIVACY POLICY

The use of patient SMS is solely for the health communication purposes between Duke City Urgent Care and it’s patients.
No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All of the above categories exclude text messaging originator opt-in data and consent; this information will now be shared with any third parties.
Duke City Urgent Care offers the option to our patients to receive text reminders, communications and information regarding their healthcare and appointments for that care. Message frequency varies. Message and data rates may apply. Reply STOP to cancel. If you require assistance please text HELP to (205)350-8000. Carriers are not liable for any delays or undelivered messages.

DCUC Responsibilities are as follows :

• We are required to maintain the privacy of your health information and to provide you with the notice of our duties and privacy practices.
• We are required to abide by terms of this notice as may be amended from time to time.
• We reserve the right to change the terms of this notice and to make the new notice provisions effective for all future PHI that we maintain. If we change the notice we will provide a copy to any persons with such request by means of in person or via US postal services.
• As a health care provider we will in good faith make an effort to obtain written acknowledgment from you in receipt of the privacy practices notice provided to you.

INFORMED CONSENT FOR VIRTUAL CARE TELEMEDICINE SERVICES

Virtual Care Telemedicine involves the use of electronic communications to enable health care providers at different locations to charge individual patient medical information for the purpose of improving patient care. Providers may include Doctors, Nurse Practitioners, or Physician Assistants. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

Patient Medical Records

• Medical Images
• Live two-way audio and video
• Output data from medical devices and sound and video files
• Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure it’s integrity against intentional or unintentional corruption.

CONSENT TO AUDIO RECORDING OF PATIENT VISIT

Patient consents to Duke City Primary Care recording of patient visit for the purposes of documenting the encounter.  Duke City Primary Care may use ambient listening on the phone or computer to assist in creating notes.  Patient acknowledges and understands that their physician must review, update, and sign the encounter records to ensure accuracy.  Patient recognizes that audio recordings will be kept in a manner consistent with the Duke City Primary Care HIPAA Privacy notice and that all recordings are destroyed within 7 days of the patient visit.

NOTICE OF PRIVACY PRACTICES

Duke City Primary Care Notice of Privacy Practices PDF is available to download here

NOTICE OF ADVANCED DIRECTIVES

Duke City Primary Care Notice Of Advanced Directives PDF is available to download here or you can request a hard copy from your clinic. This can be filled out and included in the patient chart.