PLEASE COMPLETE ALL QUESTIONS
Authorization to Treat
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.
I understand that WellBe Senior Medical providers will not provide any guarantees to me as a result of treatment and/or
I acknowledge and understand that my medical information may be released to other physicians, institutions, or agencies
accepting me for medical or institutional care. Additionally, I acknowledge and understand that my medical information
may be released to my health plan or other entities for treatment, payment or healthcare operations and that data
(medical or personal) may be released to such government agencies as is required of the medical providers of WellBe
Senior Medical by law, rules, regulation or by contract.
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.
I acknowledge that I have received a copy of the WellBe Senior Medical’s Notice of Privacy Practices.
I agree that a photocopy of this consent is as valid as the original.
Authorization for Telemedicine/Telehealth/Digital Communication
I consent to participate in a telemedicine consultation/visit, and specifically acknowledge and consent to the following:
During the 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. A physical examination of me may
Video, audio, and or photo recordings of me may be taken to document my medical condition during this visit.
The risks and benefits of telemedicine have been shared with me, including the limitation of evaluation and management. I
have been offered an in-person visit. I consent to proceed with the use of telemedicine for my visit and examination.
I have been offered an in-person visit. I consent to proceed with the use of telemedicine for my visit and examination.
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.
Medical Record Release
By signing this form, I authorize the release of my medical records or other health care information, including chart notes, reports,
correspondence, and other written information concerning my health and treatment, to WellBe Senior Medical.
Health Information Exchange (HEI) Notice. We participate in one or more Health Information Exchanges. Your healthcare providers can use this electronic network to securely provide access to your health records for a better picture of your health needs. We, and other healthcare providers, may allow access to your health information through the Health Information Exchange for treatment, payment, or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by notifying the Health Information Management Services Department OR by contacting:
WellBe Senior Medical
225 W. Washington St. Ste, 1500
Chicago, IL 60606
1 (855) 332-8527