Premier HealthCare Specialists, LLC Kim Weber MSN, APRN, AGPCNP-BC, CWN-AP Patient Information Last Name First Name Middle Name Home PhoneWork PhoneCell PhoneAddress: Street Address City State / Province / Region ZIP / Postal Code DOB MM slash DD slash YYYY Social Security No.Sex: Male Female Email Address Spouse's Name Appointment Reminder Preference: (Check "X" one) Text Call Email Pharmacy Preference: Phone:Current Home Health: Phone:CONSENT TO MEDICAL TREATMENT Patient or Responsible party or Medical POA (Power of Attorney) voluntary consent to the medical treatment/ wound care treatment by Kim Weber APRN, her associate, and/or assistants. Treatment for the wound management may include physical exam, debridement (removal of unhealthy and dead tissue from wound base to promote healing,), biopsies, laboratory assessment, diagnostic studies and procedures, imaging and/or prescription of medications appropriate for the patient. Patient agrees that the risks, benefits, treatments, and services have been discussed and explained to the patient and patient consent to treatment.Initial: CONSENT TO PHOTOGRAPHY I hereby consent and so authorize the taking of photographs by Premier HCS - staff to monitor wound progress. This consent form will be valid and remain in affect from the date of signature until the last follow up visit with the patient is fully discharged from practice..Initial: AUTHORIZATION TO RELEASE/OBTAIN MEDICAL RECORDS/PRIVATE HEALTH INFORMATIONI hereby authorize Premier Healthcare Specialists (CHECK ONE OR BOTH) To RELEASE copies of my medical records to: To RECEIVE copies of my medical records from: Name/Business Name/Business Address Street Address Address Street Address PhonePhoneI understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non-health care provider, the released information may no longer be protected by federal and state privacy regulations.Initial: NOTICE OF PRIVACY PRACTICES It is a policy of Premier HCS to release personal information only to individuals who have been authorized by the patient and/or legal guardian to receive such information for purposes of treatment, payment, and operation. The office will share all necessary information with other professional providers, insurer(s), payor(s), govemmental entities (such as Medicare, etc.) and their representative involved in the billing process (including, but not limited to claims representative, data warehouses, billing companies, and collection (HIPAA). Any information about you and/or your family will be held in the strictest of confidence by all employees. No discussions about you outside of the patient care framework will be allowed, and any conversation between staff members that pertain to delivering you quality care will be held in a confidential and professional manner. I have review the Notice of Privacy Practices and understand that by signing this form I consent to the above. I understand I may receive a printed copy of this information upon verbal or written request now or in the future.Initial: Patient's Name (Print) Date MM slash DD slash YYYY Patient's Signature (or guardian, if minor)MEDIATION AND DISPUTE RESOLUTION AGREEMENT Your care is important to us, and we feel it is vital to your treatment that we communicate open and honestly. As such, we request that you: Ask questions and participate in your care, be honest about your symptoms, and other important health information, prepare and keep scheduled visits, and be respectful to our office staff and healthcare providers. In exchange, we agree that we will: Explain diagnoses, treatment recommendations, and outcomes in an easy-to-understand way, listen to your questions, and help you make decisions about your care, keep discussions and records private, and determine when a referral or termination of care is appropriate. MEDIATION As part of our emphasis on open communication, we ask our patients to sign this mediation agreement. While we do not anticipate any issues or concerns during the course of your treatment, if any arise, you (and/ or your legal counsel) and your healthcare provider (and/or their legal counsel) agree to meet with a neutral mediator and work toward a solution. Whether or not a solution is found, mediation may postpone but does not remove or block your legal rights. Importantly, you agree that any usage or inference to a "claim" will be understood and read as a "potential claim" until the mediation is complete. This designation allows us to begin in a less formal manner that has been shown to expedite the resolution process. Your signature on this page confirms that should a concern arise in any aspect of the care provided by this office, staff, and affiliated healthcare professionals, you agree to mediate first before pursuing legal action. EXPERT WITNESSES Further, if after mediation, you still wish to purse a court action relating to your care, your signature on this page confirms that you will use, as your expert witness(es) in your legal action, American Board of Medical Specialties board-certified medical witness(es) in the same specialty as Physician. Furthermore, you agree that the physicians who you will select will be in good standing and adhere to all the rules and guidelines of professionals conduct of the American Board of Medical Specialties. As consideration for this agreement, we agree that we will adhere to these same guidelines in selecting our expert witness(es) for any court action relating to your care. I certify that I have read or had read to me the contents of this form. I understand the possible advantages that compliance with professional healthcare recommendations can provide, as well as potential consequences of non-compliance. I attest that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.Patient's or Patient Representative's Signature Date MM slash DD slash YYYY Provider's or Provider Representative's Signature Date MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
