CONSENT TO TREAT AND FINANCIAL RESPONSIBILITY GUARANTEE
CONSENT TO MEDICAL CARE: I hereby authorize the health care providers of Concierge MD LA (“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 acknowledge that no guarantees are made to me concerning the outcomes of the treatment rendered by the health care providers of the Practice.
TEST RESULTS: Due to imminent business necessity and to ensure the safety of other employees, I consent to being tested for COVID-19 as requested by my Employer and authorize my test results to be released to my Employer. I understand that lab processing can take up to 3-4 days, and the Practice is not responsible for any delays in results once the samples have been delivered to the laboratory. In the event that a sample is not able to be processed, the patient has the option to be retested at the Practice’s office without any service charge except for the lab fee.
FINANCIAL AGREEMENT: (Only Applicable to Employer or Payment Provider) I accept financial responsibility for all medical services rendered to me and agree to pay for the services in full within 3 days of receiving testing. If I fail to make such payments in accordance with the payment policies of the Practice, the Practice may terminate the “doctor-patient” relationship with me. In the event of a default of my financial obligation, the account may be turned over to an external collection agency for non-payment, 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. The permissions granted herein shall begin on the date listed below and shall remain effective until terminated by the undersigned. My signature below verifies that I have read all the information contained in this Medical Consent Form and that I have asked questions about anything I have not understood.