Electronic Consent for Treatment

I the undersigned patient, or authorized representative acting on behalf of the patient, consent to treatment of my illness(es) by the medical, dental, behavioral health staff, and other agents and/or employees of Care Resource.

I understand that my healthcare provider/team may need to request other specific written or verbal consents for certain tests, medications, treatments and procedures in the course of the study, diagnosis and treatment of my illness.

I have been told the name of the provider who has primary responsibility for my care as well as the names, professional title and professional relationships of other individuals who will be involved in my care and that there may be additional or other providers and staff involved in my care as well.

I understand that except in an emergency or extraordinary circumstances, non-routine and major medical procedures will not be performed upon me by the medical staff until I have had the opportunity to discuss and agree to them with a provider.

I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as the results of diagnoses, examinations or treatments at Care Resource.

I understand that in some cases, services could be provided via telemedicine (telehealth). Telemedicine is the use of telecommunication and information technology to provide clinical care to individuals at a distance, and to transmit
the information needed to provide that care. I am aware that not all services can be offered through telemedicine and in those cases an appointment in person will be necessary.


Record Use:
I hereby authorize Care Resource to retain, preserve and/or use my medical records for scientific research, therapeutic, commercial, or teaching purposes.

I hereby grant access to my medical records to the senior management of Care Resource for the specific purpose of evaluating the ongoing quality of care rendered by their staff. I further authorize the senior management of Care Resource to use portions of my medical records as necessary for the purposes of educating or disciplining their staff, provided that the records will not be identified as pertaining to me specifically without my expressed permission.

I hereby grant to members of the medical staff and other medical researchers use of my medical records and results for purposes of bona fide medical research. However, my records may not be identified as pertaining to me specifically without my expressed permission.

Record Release Consent:
I voluntarily authorize, give my permission and consent to the release of all my medical information and records (including any information about sensitive conditions, if any) to other institutions, agencies, health care organizations or healthcare providers who accept me for medical or institutional care. I understand that my medical information may relate to such sensitive health conditions, including, but not limited to:

A. Sickle cell anemia
B. Birth control and family planning
C. Records which may indicate the presence of a communicable disease or non-communicable disease; and tests for or records of HIV/AIDS or sexually transmitted diseases or tuberculosis
D. Genetic (inherited) diseases or tests

Further consents may be required for the following, including but not limited to:
A. Drug, alcohol, or substance abuse (42 CFR Part 2)
B. Psychological, psychiatric or other mental impairment(s) or developmental disabilities (excludes “psychotherapy notes” as defined in HIPAA at 45 CFR 164.501)

I understand that the purpose of my voluntary authorization and consent to allow use and disclosure of all my health information is for the purpose of providing me with medical treatment and related services and products, and to evaluate and improve patient safety and the quality of medical care provided to all patients.

I understand and agree that this authorization/consent form will remain in effect until expiration of this document, the day I withdraw my permission, or my death.

I understand and agree that I can revoke my authorization/consent at any time by giving written notice to Care Resource. I further consent to the release of medical information to my insurer(s) and/or pharmaceutical manufacturers and their respective agent(s) for purposes including but not limited to Utilization Review and Quality Assurance Review and to support applications for patient assistance programs.

Record Disclosure:
I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above.

I understand that there are some circumstances in which this information may be re-disclosed to other persons, only to the extent permitted by state and federal laws and regulations. I understand that once my information is disclosed, it may be subject to lawful re-disclosure, in accordance with applicable state and federal law, and in some cases, may no longer be protected by federal privacy law.

I understand that refusing to sign this form does not stop disclosure of my health information that is otherwise permitted by law without my specific authorization or permission.

I have read all pages of this form and agree to the disclosures above from the types of sources listed.

I understand that I am entitled to receive a copy of this consent and disclosure form after I sign it.

I hereby authorize payment directly to Care Resource of any benefits due to me in any pending claim and/or health insurance coverage otherwise payable to me, providing that such direct payments do not exceed the regular medical or clinical charges for such treatment. I agree that a photo static, digital of faxed copy or transmission of this authorization is as valid as the original.

I understand that my choice on whether to sign this form will affect my ability to receive medical treatment, payment for medical treatment, or health insurance enrollment or eligibility for benefits.

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