I , hereby voluntarily consent to the rendering of such care including in-person or telehealth medical evaluation, physical examination, diagnosis, lab and diagnostic testing, counseling, treatment, vaccinations or procedures by the physicians, nurse practitioners or authorized designees of Bridge to Life Clinical Consultants, as may in their professional judgment be deemed necessary to provide care for me or my dependent minor.
In making medical decisions for treatment purposes, Bridge To Life Clinical Consultants may use or release your health information to other healthcare facilities and their staff, to third party payors and other third parties as necessary to obtain payment for services rendered to you or your dependent. Bridge To Life Clinical Consultants may also seek to obtain your electronic medical record and prescription medication history from other healthcare providers, third party pharmacy benefit managers or through the Health Information Exchanges, in order to provide health care services. For additional information regarding the use and disclosure of your health information please review our Notice of Privacy Practices.
I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my condition or that of my dependent minor and that I am responsible for all reasonable charges in connection with the care and treatment for myself and/or my dependent minor.
By signing below, I am confirming that I understand the above disclosures and consent to the treatment that I or my dependent minor named below will receive.
