Policies Acknowledgement and Agreement

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. Account Balance: Should your account contain a balance, you acknowledge and understand that payment must be received prior to services being rendered. The clinic accepts a minimum of 20% of the balance due. You agree to pay the minimum of the balance in addition to any co-pays before services are rendered.

2. School Note: The clinic has the right to refuse production for an off-School Note. All off-school notes will be issued on a case-by-case basis. Should a school note be issued they may never be backtracked for dates missed prior to your visit and will only be issued for up to three days from the date of the visit. As stated, exceptions can be made on case-by-case basis. Although dates will never be backtracked, we reserve the right to include weekends or issuing more than three days given a particularly severe diagnosis. School notes will only be issued for grades k-12.

3. PE Note: The clinic has the right to refuse production for an off- Physical Education note. All off-physical education notes will be issued on a case-by-case basis. Notes will not be backtracked and can only be issued for up to a week. Should the patient need additional dates, you must return to the clinic and be re-evaluated. Or you have the option to see your primary care provider for additional care.

4. Work Note: The clinic has the right to refuse production for an off-work note. All off-work notes will be issued on a case-by-case basis. Should a off-work note be issued they may never be backtracked for dates missed prior to your visit and will only be issued for up to three days from the date of the visit (to include weekends). In addition, off-work notes will never include work-restrictions. Should you need restrictions, please contact your primary care provider. As stated, exceptions can be made on a case-by-case basis.

5. Parent Note: If you are the patient’s parent or legal guardian, an off-work note for the date of service can be issued. The note may never be backtracked and will only excuse the parent or legal guardian for the date of service.

6. Emergency Department Note: Should you be referred to the ED either by ambulance or self-transport, you acknowledge and understand that a school or work note will not be issued. You are being referred to the ED for further testing as our facility does not supply the proper diagnostic equipment (i.e. CT Scan, MRI, STAT labs, Ultrasound, etc.) to properly diagnose you. Your condition may potentially be life threatening. To ensure compliance, off-school or off-work notes will not be issued.

7. FMLA Paperwork: The clinic does not complete FMLA paperwork. By signing, you understand should you need FMLA paperwork to be completed you must follow up with your primary care provider.

8. Patient Order: You understand and acknowledge that you must register at our kiosk and wait in the office until the registration process is complete. Once completed you may ask the clinic to sign you up for our text messaging service. Should you leave the facility without the informing the clinic, once it is your turn, the clinic will not make an effort to locate you outside the building. By stepping outside you revoke your place in line and must start the registration process all over again. In addition, you understand that we see patients in the order in which they walk in and/or register online. The clinic has the right to take patients back out of order during emergent situations. Furthermore, you acknowledge, that we are not only an Urgent Care but an Occ Med clinic therefore should an injured worker arrive after you, they take precedence.

Consent for Treatment and Notice of Privacy Practices for Health Information (NPP) Acknowledgement Form

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 to treatment, which may include examination, drug screening, laboratory procedures, x-ray, local anesthesia, surgical procedures and other clinical services.

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. Patient Records: You (the patient) may request restrictions on certain uses or disclosures, inspect and obtain copies of your records, request amendments, receive an accounting of disclosures, and request confidential communications. The clinic may not use or disclose a patient’s records in any civil, criminal, administrative, or legislative proceeding against the individual without the patient’s written consent or a valid court order.

4. Insured Patients: We will bill the Patients insurance company for all the services provided during the clinic visit. Co-payments, co-insurance, and deductibles required by the insurance company must be paid by the Patient and payment may be requested before or at the time of service. In addition, if the insurance company denies all or part of the payment, the Patient agrees to be responsible to pay the amounts that are due to the clinic under the law. By signing this form 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.

5. Uninsured Patients: Patients who do not have insurance must pay the Clinic for the services provided at the time of service at our fee schedule.

6. Additional Terms: All past due accounts will be charged interest at the legal rate. If we refer the Patient’s account to a collection agency or an attorney, the Patient agrees to pay the clinic’s reasonable attorneys’ fees, costs, and collection expenses.

7. No Refunds will be issued for the office visit once an evaluation by the provider has been made.

The law requires that SoCal Emergency Medicine Urgent Care Centers give to a patient a copy of its Notice of Privacy Practices for Health Information. : I have reviewed the Notice of Privacy Practices and understand that I may request a copy of the policy at any time. By signing below, you acknowledge the reviewing of such as the Patient, the Patient’s personal representative, the Patient’s authorized agent, or an individual involved in the Patient’s medical care.

Acknowledgement and Agreement

You certify that you have read, understand, and agree to the foregoing, and have reviewed a copy of the Notice of Privacy Practices (NPP).