A verbal consent was received by you for your recent telephone encounter, please sign the bottom of this document that you are acknowledging consent for evaluation and treatment. This will allow you to have future telephone and telemedicine visits with us in the future.
Complete Spine & Pain Care offers secure viewing and communication as a service to patients who wish to view parts of their records and communicate with our staff and physicians. Secure messaging can be a valuable communications tool but has certain risks. In order to manage these risks, we need to impose some conditions of participation. This form is intended to show that you have been informed of these risks and the conditions of participation, and that you accept the risks and agree to the conditions of participation. Because the connection channel between your computer and the Web site uses secure sockets layer technology you can read or view information on your computer, but it is still encrypted in transmission between the Web site and your computer. Protecting Your Private Health Information and Risks. This method of communication and viewing prevents unauthorized parties from being able to access or read messages while they are in transmission. No transmission system is perfect, and we will do our best to maintain electronic security. However, keeping messages secure depends on two additional factors: the secure message must reach the correct email address, and only the correct individual (or someone authorized by that individual) must be able to get access to it. Only you can make sure these two factors are present. We need you to make sure we have your correct email address and are informed if it ever changes. You also need to keep track of who has access to your email account so that only you, or someone you authorize, can see the messages you receive from us. If you pick up secure messages from a web site, you need to keep unauthorized individuals from learning your password. If you think someone has learned your password, you should promptly go to the web site and change it.
Patient Acknowledgement and Agreement. I acknowledge that I have read and fully understand this consent form and the Policies and Procedures Regarding the Telemedicine/Telephone visits I agree to follow the instructions set forth herein and including the policies and procedures as set forth in the log in screen, as well as any other instructions that my physician may impose to communicate with patients via online communications. All of my questions have been answered and I understand and concur with the information provided in the answers.
I do hereby consent to treatment of my condition by the staff of Complete Pain Care LLC, its subsidiaries and affiliates. I also certify that no guarantees or assurances have been made to me as to the results that may be obtained as a result of procedures, treatments and/or techniques used by Complete Pain Care LLC, its subsidiaries and affiliates. I further understand that while I am being assessed and/or treated at Complete Pain Care LLC, its subsidiaries and affiliates will not be held responsible for any injury sustained outside of immediate physical premises. I understand that it is the policy of Complete Pain Care not to prescribe medication on the initial visit. I certify that I (or my dependent(s)) have active and valid insurance coverage and have supplied Complete Pain Care, LLC with the up-to-date and correct insurance identification card(s) as well as all necessary information regarding the guarantor of the insurance policy(ies) and the subscriber as is required to submit medical claims for reimbursement. I understand that failure to provide updates to any of the information supplied may result in denial of payment(s) to Complete Pain Care, LLC. I understand that resubmitted claims with corrected updated information may still be denied due to the fact that the corrected information was not supplied in a timely fashion.
I, the undersigned Patient assign all rights and benefits of insurance of any and all applicable medical payments and/or other insurance (including legal suits if applicable) to Complete Pain Care LLC and/or its affiliates and subsidiaries for services and/or supplies to the undersigned Patient and Worker’s Compensation or other insurance coverage under my policy, in accordance with Mass. General Laws Ch. 90. Sec. 34M. I hereby instruct the insurance carrier that in the event my medical benefits are disputed for any reason, (including medical relatedness, reasonableness and/or necessity) or any take back by the insurance carrier, that the amount of benefits claimed by Complete Pain Care LLC is to be set aside and not disbursed until the dispute is fully resolved. I understand that it is my responsibility to pay Complete Pain Care, LLC for those medical services rendered to me or my dependent(s). I understand that I am financially responsible and I personally guarantee payment for all charges whether or not paid by insurance. I understand that this consent is valid for two years from the date below.