Consent to Treatment — Cabot Medical

I. Consent for Medical Care, Testing, and Treatment

I voluntarily consent to treatment which may include a complete medical history, physical examination, performance of diagnostic procedures, lab tests, x-rays, and other medical procedures as deemed necessary and appropriate by the physician, physician assistant, nurse practitioner and/or associates, including residents, students, nurses, technicians, and assistants (each a “Provider”) participating in my care on behalf of Cabot Medical, PLLC (“Cabot”). I understand that, absent an emergency or extraordinary circumstance, I have the right to discuss all procedures or treatments with any Provider participating in my care, and to refuse any proposed procedure or course of treatment.
I am aware that the practice of medicine and surgery is not an exact science, and that results and outcomes of treatment are different for each patient. I acknowledge that no guarantees or promises have been made to me regarding my health or the results or outcomes of any procedure, test, or treatment that I authorize my Provider to perform.
I voluntarily consent to telemedicine which includes video, audio, asynchronous messaging, digital platform, remote evaluation, or electronic communication.
I authorize Cabot to dispose of any specimen or tissue remaining after completion of a clinical procedure or treatment.
I understand that in the rare event that a Provider is exposed to my blood and/or body fluids, Cabot may perform laboratory studies on my blood to detect the presence of any serious communicable diseases, such as hepatitis, HIV or AIDS. I understand Michigan law permits this testing without my consent and, should such testing occur, I will not be charged.

II. Notice of Privacy Practices Acknowledgment and Release of Health Record Information

I acknowledge that I was offered and/or provided Cabot’s Notice of Privacy Practices, and that I may obtain an additional copy of the Notice at any time. This Notice describes how Cabot uses and discloses protected personally identifiable information, including billing and medical information, in accordance with the protections of the law.
I understand that Cabot may release my personal, billing, and medical information to other institutions, facilities, providers, payers, insurance companies or review agencies for use in connection with my current or future care, health care operations, including quality improvement and care coordination, or as required for Cabot or Providers to receive payment for care. I understand and agree that this may include the following: (i) alcohol and drug abuse records protected under the regulations in 42 Code of Federal Regulations, Part 2; (ii) information related to HIV infection or AIDS; (iii) psychological records, social services records, and confidential communications made to a psychologist, social worker, or other provider.
I understand and acknowledge that my information can be shared by Cabot with other past, future, and current providers, caregivers, and facilities to coordinate my health care, for payment and for administrative purposes, including quality and care management, or as otherwise permitted or required by law. This information may include dates and services provided, location where treatment was received, treatment information, medications, diagnoses, names of physicians and other health care providers, including mental health professionals, and information related to diagnosis, care, or treatment of my mental or emotional condition.
I acknowledge that my health record information may be released to my employer if this is a work-related exam or an injury for which a workers compensation claim has been filed.

III. Authorization for Payment / Financial Responsibility

I assign and authorize payment directly to Cabot for all services rendered.

IV. Additional Acknowledgments

Communication Methods: I agree that Cabot and its business associates may contact me by any phone number provided by me or associated with my health record. Cabot may contact me by sending text messages or emails, using the contact information I provide. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device. I understand that I can choose not to participate in some or all these methods by completing an opt out form.