Patient Consent form for
Medical Treatment

Consent for Medical Treatment. I give consent to Premier Assist LLC, and its staff, physicians, and other practitioners (collectively, the “Practice”) to provide and perform, either in person or via telehealth, such medical care, tests, procedures, and other services that are deemed necessary or beneficial by the Practice for my health and wellbeing.

Authorization of Payment of Insurance Benefits. I authorize payment to the Practice of all monies and/or benefits to which I may be entitled from government agencies, insurance carriers, or others who are financially liable for my medical care and treatment, to cover the costs of care and treatment. I hereby authorize the release of any and all medical records about me for purposes of payment for services rendered.

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Authorization for Release of Information. By acknowledging this consent electronically, I authorize the Practice to release my health information: (1) to any requesting healthcare provider for my further diagnosis, care, or treatment, or for that provider’s payment or healthcare operations; (2) to any person or entity responsible for billing or collection of claims for medical services or products; (3) to any person or entity that is, or may be, liable to the Practice or me for all or part of the Practice’s charges, including third-party payors; (4) to any government agency or other organization responsible for oversight of the Practice or a third-party payor; and (5) for the Practice’s normal healthcare operations.

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I consent to the Practice accessing my medication history information electronically through a secure connection to Surescripts, or a similar service, using its e-prescribing applications.

I grant permission and consent to the Practice to contact me using the phone number(s) and email address(es) I provide, including permission to (1) leave voicemail messages; (2) send text messages or emails; and (3) use prerecorded or artificial voice messages and/or automatic dialing systems in connection with communications related to my care, scheduling, billing, or healthcare operations. I understand that such communications may result in charges depending on my service plan, and the Practice is not responsible for such charges.

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Filming. I understand that photographs or other images of me may be recorded for the Practice’s treatment and quality assurance purposes. To the extent such images identify me, they will receive the same confidentiality protections as my other health information.

Acknowledgment of Notice of Privacy Practices. I acknowledge that I have been provided access to the Practice’s Notice of Privacy Practices and have had the opportunity to review and understand my rights.

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Electronic Acknowledgment. I confirm that I have read and understand this consent form in full and agree to its terms by reviewing and acknowledging it electronically.