Consent for Treatment/Care
I understand that is Consent for Treatment/Care applies to Kaskaskia Sugar, PLLC and its employees. I consent to treatment and care by Kaskaskia Sugar, PLLC and by their providers, employees and/or authorized agents of the Kaskaskia Sugar, PLLC as they judge is in my best interest. This may include orders for routine diagnositic, radiology and laboratory procedures, photographs provided by the patient to help with a diagnosis and/or treatment of a condition, and medication administration. I acknowledge that no guarantees have been made as to the effect of such treatment and care on my condition. I undersand that consent is being given in advance of any specific diagnosis and/or treatment and intend this consent to be continuing in nature even after a specific diagnosis has been make and/or a treatment recommended. Authorization to Release Information I hearby authorize Kaskaskia Sugar, PLLC to use and/or disclose my health information for purposes related to treatment, payment for care and/or health care operations. Authorization of Payment I hearby authorize payment of benefits to Kaskaskia Sugar, PLLC. I understand that I am financially responsible for any charges of sought treatment. In consideration for the services to be rendered, I individually obligate myself to pay the account of Kaskaskia Sugar, PLLC in accordance with the rates and terms of Kaskaskia Sugar, PLLC. I understand that Kaskaskia Sugar, PLLC will request services paid before appointment may be scheduled. Scheduled appointments and payment of services is authorizing agents of Kaskaskia Sugar, PLLC to treatment and care as they judge is in my best interest. Refunding of payment is not warranted if services have been provided, if the provider cancels the appointment before the date and time of the appointment, or if the patient cancels the appointment within twenty-four (24) hours of the appointment date and time. In the event of non-payment, I agree to pay all reasonable costs of collection, including attorney fees. I understand that Kaskaskia Sugar, PLLC does not accept medical insurances and is a full payment provider. Kaskaskia Sugar, PLLC will provide the patient with the appropriate coding on the patient’s receipt so they may submit to their private insurance company for reimbursement. Consent to Wireless Calls, Texts and Emails I consent to receive calls, texts and e-mails from Kaskaskia Sugar, PLLC, its agents and representatives at the number and e-mail address I provide during my registration for the following purposes: appointment reminders, general health reminders, servicing my account, collecting amounts due and patient experience feedback. Message may be generated and sent using an automated notification system. Messaging may be prerecorded and delivered. I understand that message and data rates may apply. I understand that I have the right to revoke this consent by contacting Kaskaskia Sugar, PLLC via email at kaskaskiasugarpllc@icloud.com. I understand this form and its content and significance. I certify that I have read the foregoing and am the patient or the patient’s parent/legal representative.
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