Hoag Clinic – Hoag Compass – Hoag On-Demand – Conditions of Treatment
Name: [LAST] [FIRST] [MIDDLE]
Date of Birth: [INSERT]
Consent to Treatment
I hereby consent to all health care treatment and procedures provided by Hoag Clinic, its physicians, clinicians, and other personnel. Such treatment and procedures may include diagnostic, therapeutic, imaging, and laboratory services.
Financial Responsibility
I hereby assign and authorize direct payment to Hoag Clinic of any insurance benefits otherwise payable to me or on my behalf for the services rendered. It is agreed that payment to Hoag Clinic, pursuant to this authorization, by an insurance company shall discharge the insurance company of any and all obligations under a policy to the extent of such payment. I understand that I am financially responsible for changes not paid according to this assignment. I hereby attest that the insurance information provided to Hoag Clinic is accurate, and that I am an eligible member. I understand that I am responsible for knowing my benefits/coverage and acknowledge that tests ordered by my physician may NOT be covered by my insurance company.
I understand that I will be charged a 1% per month finance charge on all accounts over 90 days. I hereby authorize the release of all information to other physicians and insurance carriers for the purpose of payment for medical services, and further treatment of care by another physician. I further agree that a photocopy of this form shall be as valid as the original.
Payment is due at the time services are rendered. All charges are my direct responsibility. Hoag Clinic cannot render medical services on the assumption that charges will be paid by my insurance company. If Hoag Clinic has problems collecting payments from me, Hoag Clinic will also add attorney’s fees, collection agency costs and any related fees to my bill.
Patient Portal
Hoag Clinic utilizes a Patient Portal, which allows me to electronically access my medical information. By click-signing this form, I hereby request and agree that my medical information and laboratory test results may be provided to the Patient Portal, so that I may access them electronically as part of my clinical health record. I understand that, unless certain conditions are satisfied, the laboratory test results made available through the Patient Portal will not include test results for HIV, hepatitis, drug abuse, or routinely processed tissues.
Communication Consent
By providing my cell, landline, or any other phone numbers, I expressly consent to receiving communications from Hoag Clinic, staff, contractors, collection agents, and others, at any number I provider or that are later acquired for me. These parties may use this information to contact me by live agent, voice mail, text message, using an auto-dialer or other computer assisted technology, pre-recorded message(s), or by any other form of electronic communication for any purpose, including but not limited to, appointment and follow-up health care reminders, scheduling, my account(s), providing feedback on Hoag Clinic services, assignment of benefits, and/or financial responsibility. I understand that depending on my phone plan, I could be charged for these calls or text messages. I further understand that I can opt out of receiving text messages at any time by replaying “STOP” from my mobile device. I agree to provide new number(s) if my number(s) change. Providing these numbers is not a condition of receiving healthcare services.
Health Information Exchange
Hoag Clinic may participate in one or more health information exchanges (HIEs) and may electronically share your medical information for treatment, payment and healthcare operations purposes with other participants in the HIEs. HIEs allow your health care providers to efficiently access and use medical information necessary for your treatment and other lawful purposes. The inclusion of your medical information in an HIE is voluntary and subject to your right to opt-out. If you do not opt-out of this exchange of information, we may provide your medical information in accordance with applicable law to the HIEs in which we participate. You can choose not to have your information shared through any of our HIE networks (that is, “opt out”) at any time. You may do this by contacting the Hoag Health Information Management Department at (949) 764-8326, Option 5 or HoagMedicalRecords@hoag.org.
Consent to Telehealth Services
Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care.
There are some benefits of receiving health care services through telehealth, such as improved access to care, and convenience. There are also some limitations to receiving health care services through telehealth. The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. Similarly, there are risks associated with participating in telehealth, including a risk of technical failures during the telehealth visit beyond the control of Hoag Clinic.
Our telehealth providers do not address medical emergencies. If you believe you are experiencing a medical emergency, you should dial 9-1-1 and/or go to the nearest emergency room.
□ ACCEPT. By clicking “Accept”, I acknowledge that I have carefully read, understand, and agree to the terms of this Hoag Clinic Conditions of Treatment form.
Patient’s Name: [INSERT] Date: [INSERT]
Or if signed by other than patient, indicate relationship: [INSERT]
Name (Legal Representative): [INSERT]