1. CONSENT TO HALAH HEALTHCARE SERVICES
I request and authorize Halah Healthcare Professionals as my healthcare provider. This care may include, but is not limited to, routine diagnostics, radiology and laboratory procedures, administration of routine drugs, biological and other therapeutics, and routine medical and nursing care.
I authorize my physician(s) to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I understand that my (the patient) care is directed by my physician(s) and that other personnel render care and services to me (the patient) according to the physician(s) instructions.
● I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees or promises have been made to me with respect to results of such diagnostic procedure or treatment.
● I understand that samples of body fluids and/or Tissues may be withdrawn from me (the patient) during routine diagnostic procedures. I authorize Halah Healthcare Services to dispose of the bodily fluids.
● A drug screen by blood or urine sample may be obtained with verbal consent for purposes of verifying compliance with medication regimens or when signs or symptoms of toxicity exist.
● If provided any healthcare support or medical equipment(s) / gadget(s), I understand this is also the property of Halah Healthcare Services and that as such, it will need to be returned upon completion of treatment.
2. ACKNOWLEDGEMENT OF PRIVACY PRACTICES
The Halah Healthcare Services Notice of Privacy Practices provides information about how protected health information about me (the patient) is managed and shared. I understand that the terms of the Notice may change, and I may refer to the website of Halah Healthcare Services to obtain the updated copy.
3. AUTHORIZATION TO RELEASE HEALTH INFORMATION
I understand that as part of my healthcare, Halah Healthcare Services, originates, maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
● A basis for planning my care and treatment
● A means of communication among the many health professionals who contribute to my care
● A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
I acknowledge that a copy of Notice of Privacy Practices was provided to me. I understand that I have the following rights and privileges:
● The right to review the notice prior to signing this consent
● The right to object to the use of my health information for directory purposes
● The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations.
I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me.
I further understand that Halah Healthcare Services reserves the right to change its notice and practices. Should Halah Healthcare Services change its notice, it will be uploaded on the website.
4. INFORMED CONSENT FOR TELE-HEALTH SERVICES
Tele-health involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and use of live two-way audio and video.
By signing this document, I attest that I understand the following:
● I understand that the laws that protect privacy and the confidentiality of medical information also apply to tele-health. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data.
● I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
● I understand the alternatives to telehealth consultation as they have been explained to me, and in choosing to participate in a telehealth consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, at a testing facility at the discretion of the consulting healthcare provider.
● I understand that the anticipated benefits from the use of telehealth in my care cannot be guaranteed or assured.
● I have read, understand, and agree to the information provided above regarding tele-health.
5. CONSENT TO THE RELEASE OF MEDICAL INFORMATION
I authorize the release of health information from other medical entities to be transferred to Halah Healthcare Services to expedite the provision of quality care on my behalf/the behalf of my loved one. This includes, but is not limited to, inpatient hospital and rehab reports and discharge paperwork, skilled care records, diagnostic reports, and documents pertaining to any and all outpatient medical services.
I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses. I understand and acknowledge that I have received a Notice of Privacy Practices and I consent to such disclosures as delineated in the Notice.
I HAVE READ OR HAVE HAD READ TO ME AND FULLY UNDERSTAND THIS CONSENT; I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND HAVE HAD THESE QUESTIONS ADDRESSED TO MY SATISFACTION.
Patient’s name
Patient’s signature Date
OR
Name of person authorized to sign on behalf of patient
Responsible party’s signature Date