Authorization to Treat

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Patient First Name*
Patient Last Name*
Date of Birth*
Address*
  1. I consent to allow WellBe Senior Medical to provide diagnostics and other healthcare related services. I understand that these services may include examinations and treatments and providers will not provide any guarantees to me as a result of treatment and/or examinations.
  2. I consent to allow WellBe Senior Medical to release my information and records to my health plan, its agents and representatives in accordance with the law and this agreement.
  3. I acknowledge and understand that my medical information may be released to other physicians, institutions and agencies accepting me for medical or institutional care.
  4. I understand that the laws that protect the confidentiality of my medical information also apply to Telemedicine, and that no information obtained which identifies me will be sold, shared, or disclosed to other entities without my consent.
  5. I acknowledge that I have received a copy of the WellBe Senior Medical’s Notice of Privacy Practices and I may contact WellBe in writing regarding my rights and options explained in the Notice of Privacy Practices.
  6. I understand I may be sent appointment reminders, emails and SMS messages regarding my care and that I can cancel these messages at anytime per CMS guidelines.
Consent

Authorization for Telemedicine/Telehealth

  1. I consent to participate and proceed with a telemedicine consultation/visit and I acknowledge that I have been offered alternatives to my telemedicine consultation.
  2. I acknowledge and understand the risks and benefits of telemedicine have been shared with me including the limitation of evaluation and management.
  3. I consent and understand that during my telemedicine consultation/visit, details of my medical history, examinations, x-rays and tests will be discussed through the use of interactive audio, video, and/or telecommunication technology.
Consent
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Request for Access

Please consider this a request for the exercise of my rights under federal and state laws to access my healthcare information. I understand that my request will be acted upon no later than the timeframes allowed by federal and state laws. I request the release of my medical records or other healthcare information, including chart notes, reports, correspondence, and other written information concerning my health and treatment, to WellBe Senior Medical.

Consent
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