Low-cost mobile clinic for people who have no health insurance
CONSENT TO DIAGNOSIS AND TREATMENT
Emergency: If this is an emergency, I will dial 9-1-1 on my telephone. Affordable Mobile Doctor does not provide emergency medical care. I understand that I am responsible for all cost associated with emergency care.
Communication: I agree to call +1 (480) 357-6275 and talk to a live person if I need to contact AMD for any reason. I understand that I should not expect a response from emails, text messages, faxes, voicemail. I understand texting is available as a courtesy but will follow up if I do not receive a response.
Payment: I understand that payment must be made in full prior to the doctor visit. I understand that payment is for one medical concern during a five (5) minute consultation by a licensed physician. Multiple concerns require multiple doctor visits. Payment arrangements are not available. Payment for a consultation may not result in the requested prescription, and the doctor has the right to not prescribe requested medications if the medication is not indicated or may cause harm. Furthermore, there are conditions the doctor does not treat, and there are drugs the doctor does not prescribe. I understand that service fees (including laboratory services) are NEVER, under any circumstance, refunded. I understand that Affordable Mobile Doctor does not bill insurance nor does medical billing or coding for insurance purposes. I understand that if have have medicare or medicaid I do not qualify for services provided by Affordable Mobile Doctor.
Interpretation of Results: Results for labs and imaging require a follow up visit for interpretation. Each doctor visit is limited to one medical concern, therefore, the follow up visit for interpretation of results is limited to that task. I will make an additional appointment if I have additional medical concerns. Laboratory services provided by Professional Co-op can not be refunded. Under some special circumstances, I may have credit to use as I like for services provided (doctor visits, procedures, Professional Co-op services).
Fees for Ancillary Services: As a patient of Affordable Mobile Doctor, I understand that doctor dispenses no medicine, and all prescriptions, including pharmaceuticals, herbs, vitamins and nutrients, are an additional cost to the doctor visit. I understand that I am financially responsible for all fees associated with the cost of care for ancillary services such as labs (with exception of Professional Co-op services) and imaging. These fees are to be paid directly to the provider (e.g.Fry’s Pharmacy, Bashas’ Pharmacy, SimonMed Imaging, LabCorp, Westcoast School of Ultrasound etc.)
Voicemails: I understand that Affordable Family Clinic needs to speak directly to me and will not violate HIPAA by emailing, texting, faxing or leaving voicemails containing protected health information. I will call +1 (480) 357-6275 until I speak to a person if I have any issues, concerns, comments or needs.
No Mutual Exclusivity: I understand that any treatment or recommendations provided to me as a patient of Affordable Mobile Doctor is not mutually exclusive from any other treatment or advice that I may be receiving now or in the future, from another healthcare provider. I am at liberty to seek or continue medical care from a physician, surgeon, or other healthcare provider.
Treatment Variance: I understand that Affordable Mobile Doctor offers integrative family medical care. For instance, if an antibiotic is indicated and prescribed, the doctor will most likely recommend probiotics. Allopathic, Naturopathic, Homeopathic, or Chinese medical therapies provided by Affordable Mobile Doctor may be different from those usually offered by another licensed healthcare provider. Not all therapies are FDA approved. I will ask the doctor during my consultation for more details if I am concerned about my specific treatment plan.
Aggravation of Symptoms: I understand that Allopathic, Naturopathic, Homeopathic, or Chinese medical treatments can lead to a temporary aggravation of symptoms. Should I experience any symptoms which I associate with any part of my prescribed treatment, including, but not limited to, procedures, alternatives, risks, I understand that I should promptly call 9-1-1 if it is an emergency. In the event that it is not an emergency, I will call Affordable Mobile Doctor at +1 (480) 357-6275 and continue calling until I speak to a live person.
Side Effects: I understand that any treatment (including but not limited to Prescriptions of drugs (legend and over-the-counter drugs, herbs, vitamins, minerals, etcetera), Acupuncture, Intravenous Nutrient Therapy, and Manipulation) intended to help may have side effects. While the chances of experiencing complications are small, it is the practice of Affordable Mobile Doctor to inform patients about them. These complications may include, but are not limited to, soreness, temporary pain or discomfort, inflammation, soft tissue injury or bruising, dizziness, and temporary worsening of symptoms. More serious complications are extremely rare. I understand that additional information on side effects and complications is available upon request. I understand it is my responsibility to seek medical attention IMMEDIATELY (for example, call 9-1-1) if I think I am having a serious or life-threatening reaction, and I agree to follow up with the doctor as soon as possible. It is also clinic policy to inform me of the procedure being performed and the risks and alternative treatments available. If my physician does not explain to my satisfaction, I will ask for more information, and I will ask any questions I have.
Expiration Dates: I understand that I must consent to treatment and diagnosis and have had a consultation with the doctor in the past six (6) calendar months in order to be an established patient. I understand that I must be an established patient in order for the doctor to diagnose or treat me. I understand that all orders, including but not limited to, recommendations, treatments, procedures, prescriptions, laboratory services, imaging, etcetera expire six (6) months from the last date of service. I understand it is my responsibility to follow the doctors orders and recommendations in a timely manner.
Medical Records: I agree to create a patient portal with LabCorp for copies of lab reports. I agree to make a verbal request for chart note prior to my consultation at which I will obtain said records. The doctor will automatically provide a copy of imaging reports at my follow-up consultation. It is my responsibility to keep all of my medical records. I understand that if I am seeking SSI/SSDI/disability, workers compensation, or other litigious administrative services, I will not use the services of Affordable Mobile Doctor. I understand that I will not use a third party to request medical records.
HIPPA NOTICE OF PRIVACY PRACTICES: I have read and understood the HIPPA NOTICE OF PRIVACY PRACTICES and have access to this information. I have had the opportunity to ask questions.
Consent to Diagnosis and Treatment: By making the statement, “I consent to diagnosis and treatment by the doctor” means I have read and understand the above and have had an opportunity to ask questions. I hereby consent to treatment.