New Patient Consent to Treatment

Please review and complete the Consent to Treatment form below. Once submitted, you’ll be taken directly to the New Patient Packet to continue your registration.

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CONSENT TO TREATMENT

Patient Name(Required)

Date of Birth(Required)

Authorization for Medical Treatment

I voluntarily consent to and authorize the physicians, nurse practitioners, physician assistants, nurses, medical assistants, and other healthcare personnel affiliated with Emkey Arthritis and Osteoporosis Clinic ("EAOC") to provide medical care, treatment, diagnostic procedures, examinations, laboratory testing, injections, infusions, and other healthcare services deemed necessary for my diagnosis and treatment.

I understand that the practice of medicine is not an exact science and that no guarantees or assurances have been made regarding the results of my care or treatment.

Release of Information for Treatment, Payment, and Healthcare Operations

I authorize EAOC to use and disclose my protected health information as necessary for:

Medical treatment and coordination of care
Insurance verification and claims processing
Payment activities
Healthcare operations as permitted by applicable law

Assignment of Insurance Benefits

I authorize payment of medical benefits directly to Emkey Arthritis and Osteoporosis Clinic for services rendered.

I understand that I am financially responsible for any charges not covered by my insurance carrier, including deductibles, copayments, coinsurance amounts, and non-covered services.

Consent for Routine Communications

I authorize EAOC to communicate with me regarding appointments, treatment recommendations, test results, prescription information, billing matters, and other healthcare-related information via:

Authorized Communication Methods

Phone Call

Voicemail

Text Message

Patient Portal

Telehealth Services (If Applicable)

I understand that some services may be provided through telehealth or other electronic communication methods when appropriate and available.

I acknowledge that:

Telehealth may involve the electronic transmission of my health information.
Reasonable efforts will be made to protect my privacy.
I may refuse telehealth services and request an in-person appointment when appropriate.

Initials

Acknowledgment

I certify that I have read and understand this Consent to Treat. I have had the opportunity to ask questions regarding my treatment and the policies of the practice. I understand that I may revoke certain authorizations in writing as permitted by law.

By signing below, I voluntarily consent to treatment and healthcare services provided by Emkey Arthritis and Osteoporosis Clinic.

Who is signing this consent?(Required)

Patient

Parent/Guardian/Personal Representative

Patient Name (Print)(Required)

Patient Signature(Required)

Date(Required)

If Patient is a Minor or Unable to Sign

Parent/Guardian/Personal Representative Name(Required)

Relationship to Patient(Required)

Signature(Required)

Date(Required)

By clicking CONTINUE TO NEW PATIENT PACKET you will complete this step and your information will be submitted. You will automatically be directed to the next step in the new patient registration process.