Patty Stark General Consent for Treatment / Policies

CONSENT FOR MEDICAL CARE

I give consent to Patty Stark, its staff, physicians and other practitioners (collectively, the “Practice”) to provide and perform such medical care, tests and other services that are deemed necessary or beneficial by the Practice for my health and well-being.

I understand that the Practice is entirely virtual (“telemedicine” or “telehealth”) and that I will not be evaluated in person. Therefore certain limitations exist regarding diagnostic capabilities within the Practice (for example but not limited to assessment of vital signs or performance of a physical exam).

I understand that the Practice is considered adjunct, consultative care and is not considered to be a provider of my primary, acute or urgent care at any time. I acknowledge the need to obtain and maintain a relationship with a primary care provider of my choice to provide advice and treat any acute, chronic or urgent medical needs that are unable to be addressed in a consultative telemedicine/virtual practice environment by the Practice. I understand that my primary care professional may not agree with the necessity for – or the Practice’s interpretation of – any particular care, test or other service provided by the Practice. If I have any concerns regarding this, I agree to discuss them with the Practice and with my primary care professional.

I understand that the Practice is not available to address urgent or acute care needs. The Practice does not maintain an answering service or any “on-call” services to address any medical needs. I agree to have any urgent, acute or emergency care needs addressed by contacting my primary care provider’s office, calling 911 emergency services or by proceeding to an urgent care facility or the emergency department of a hospital, whichever is appropriate.

FEES AND PAYMENT POLICIES

Fees:Fees for products and services provided by Patty Stark are charged by hour. The fee schedules have been established after careful consideration of what is just and fair based on the specialized services provided. This takes into account the experience and expertise of our staff and the customary fee in our geographic area.

Cancellation Policy: Your appointment time is reserved for you. The hourly fee for any missed appointments is charged and will not be refunded unless you provide the office with at least 24 hours prior notice

Payment: Payment is required at the time of scheduling a service via credit card or HSA card. You will be required to provide a credit card number to be kept on file for forgotten payments, missed appointments, and out of office appointments. Returned checks and late payments may be subject to an additional late payment fee. Failure to pay your bill in a timely manner or ongoing noncompliance with payment terms may incur collections charges and your bill may be sent to a collection agency.

Missed Payments:All products and services need to be paid in full at the time the product or service is either scheduled or provided to you. Should you miss more than one appointment, or any payment due to decline of your credit card on file or failure to provide payment, your provider’s practice will discuss with you plans to resolve your balance prior to, but not later than the beginning of your next appointment. Late fees may be assessed. All outstanding balances must be resolved by the end of each calendar month, in order to avoid certain late charges.

INSURANCE

We do not accept insurance. Patty Stark providers do not participate in any managed care networks or any type of insurance, including Medicare, CHAMPUS/TRICARE, Medicaid or private plans. You may request an insurance reimbursement invoice to submit to your insurance. InnovoWell’s providers are considered “Out of Network Providers,” as they are not participating providers of any insurance plans.

Medicare/Medicaid: Patty Stark’s providers have opted out of Medicare and other government medical payment programs. Usual Medicare limits to charges and services do not apply. By choosing to work with Patty Stark, the patient and/or their legal representative acknowledge that the patient chooses to completely forego the use of any Medicare, Medicaid, CHAMPUS or TRICARE benefits for services provided by Patty Stark and agrees that neither the patient nor any representative will file any claims to Medicare, Medicaid, CHAMPUS or TRICARE, nor will ask the provider to do so. Government payments will not be made for any products or services through Patty Stark, including that of any particular service provided that may have been otherwise eligible for submission to any government payor were it not for the presence of this private contract. Medigap plans and other supplemental plans may elect not to reimburse for products or services provided by Patty Stark, which are not covered by Medicare. The patient acknowledges that he/she freely enters this contract with the knowledge of the patient’s right to obtain Medicare covered services from providers who have not opted out of Medicare, and understands that the patient is not compelled to enter into private contracts with providers who have opted out of Medicare.

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