In this document SoCal Emergency Medicine Urgent Care Centers is referred to as Clinic and person signing
this document is referred to as You or Patient. You acknowledge and agree to all of the following:
1. CONSENT: Consent to treatment, which may include examination and COVID 19 testing.
2. The law provides that the consent of the Patient be obtained so that the clinic may use or disclose medical information to the Patient.
3. INSURED PATIENTS: We will bill the Patients insurance company for all the services provided By signing thisform you authorize us to submit a claim for payment to the Patient’s insurance company for services provided to the Patient. You also authorize the insurance company to make direct payments to us for such services.
4. UNINSURED PATIENTS: SCEM will bill the CARES Act with a valid Social Security Number.
5. PERSONS AUTHORIZED TO DISCLOSE PROTECTED HEALTH INFORMATION: I authorize the following person
(s) to disclose health information about patient: SCEM Urgent Care Centers
6. DESCRIPTION OF INFORMATION: This authorization permits the release of COVID-19 test results
7. AUTHORIZED USERS AND RECIPIENT. I hereby authorize the following person or class of persons to receive and or use the health information described in section 2 above. Hemet Unified School District
8. PURPOSE: I hereby authorize the information in section 2 above to be used and or disclosed for the following purposes: Requested by patient.
9. RIGHT OF REVOCATION. I understand that I have the right to revoke this authorization at any time, provided that my revocation is in writing or in person at Southern California Emergency Medicine Urgent Care Centers.
10. LIMITS TO REVOCATION. I understand that my revocation will be effective upon its receipt by the person(s) I authorized in Section 1 but would not be effective to the extent that such persons have acted in accordance with this Authorization and in reliance thereon. With respect to the person (s) I authorized to receive and use health information described in Section 3, if patient (or personal representative) requested this Authorization, any revocation will be effective only when I communicate my revocation directly to them.
11. REDISCLOSURE. I understand that if the recipient of my information in Section 3 above is not a healthcare provider, a health plan or health care clearing house or not an entity required to comply with federal or state health privacy regulations, my health information may be further disclosed by such recipient and my information may no longer be protected by state and federal laws. If this Authorization is for the disclosure of substance abuse information, the recipient may be prohibited from disclosing the substance abuse information under federal substance abuse confidentiality requirements.
12. CALIFORNIA/ARIZONA RESTRICTION. I understand that a recipient of medical information in California or Arizona may not further disclose medical information about me (patient) unless a new Authorization form is signed by me or my personal representative or unless the disclosure is specifically required or permitted by law.
13. RIGHT TO REFUSE TO SIGN: I understand that I do not have to sign this authorization and that my failure to sign this authorization will not affect my ability to obtain COVID-19 testing.
14. AUTOMATIC ONE-YEAR DURATION. This authorization will automatically expire after one (1) year from the date of execution unless a different end date or event is specified.