:: Policies ::
CONSENT TO TREAT
PRIOR TO NEW OFFICE VISIT OR ANNUAL VISIT DOWNLOAD, FAX, MAIL, OR BRING WITH YOU THIS FORM
CONSENT TO MEDICAL CARE AND TREATMENT
I, __________________________ , authorize and consent to medical, surgical and office treatment and procedures to be performed as deemed necessary for my medical care. I elect to be fully informed with advance notice of the nature and character of the proposed treatment, its anticipated results, possible alternatives, and the risks, complications, and anticipated benefits involved in the proposed treatment and the alternative forms of treatment, including non-treatment.
This treatment will be with the supervision of a licensed staff physician ,DR Vincent Jarvis MD MPH and or assisted and diagnosis treatment by and coordination of care by clinician Marc Gossin RPA and/or said staff of Always Your Choice medically licensed employees.
The entire treatment will be in the sole discretion of the attending physician, such care, treatment and procedures are necessary or advisable in the interest of my health and well-being.
I will abide by such responsibilities in my health care contained in the following guidelines :
Provision of Information-A patient has the responsibility to provide, to the best of his knowledge, accurate and complete information about present complaints, previous illnesses, hospitalizations, medications and other matters relating to his health. He has the responsibility to report unexpected changes in his condition to the practitioner. A patient is responsible for reporting whether he clearly comprehends a contemplated course of action and what is expected of him.
Compliance with Instructions -A patient is responsible for following the treatment plan recommended by the practitioner responsible for his care. This may include following the instructions staff relayed from the health care practitioners .of nurses They carry out the coordinated plan of care, implement the responsible practitioner's orders and suggest appropriate treatment fo speed in recovery. The patient is responsible for keeping appointments and, when he is unable to do so for any reason, notifying the office as soon as possible..
Refusal of Treatment - The patient is responsible for his actions if he refuses treatment or does not follow the practitioner's instructions.
Office Charges -The patient is responsible for assuring that the financial obligations of his health care are fulfilled as promptly as possible. If there is a billing issue notify Mr Michael Goldman at Quailty Medical Billing of which the phone number and address will be provided upon request.
Respect and Consideration - The patient is responsible for being considerate of the rights of other patients and office staff personnel
Complaints and Concerns If you have a complaint and/or concern regarding care or treatment rendered at Always Your Choice please immediately notify: Marc Gossin RPA either in person or in writing in regard to any unpleasantness..
| Date____________ | Signature of Patient __________________ |
| Witness _________________ | Date ___________ |