General Consent for Care and Treatment Concern
To The Patient: You have the right, as a patient, to be informed about your condition and the recommended medical or
diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or
procedure knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been
recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to
identify the appropriate treatment and/or procedure for any identified condition(s).
- CONSENT FOR TREATMENT- I voluntarily consent to outpatient care and treatment performed by my
physician and all other healthcare providers at Magnolia Family Medicine. I also consent to routine services,
diagnostic procedures, medical treatment, and other health care testing and treatments deemed necessary by
the health care providers treating me. I understand that if additional testing is recommended, I will be asked
to read and sign additional consent forms prior to the test(s) or procedure(s).
- CONSENT FOR TREATMENT OF A MINOR - I hereby state that I have legal custody of the aforementioned
minor and that I voluntarily grant my authorization and consent for the minor child to be treated for routine
services, diagnostic procedures, medical treatment, and other health care testing and treatments deemed
necessary by the health care providers treating said minor.
- RIGHT TO DISCUSS TREATMENT PLAN -you have the right to discuss your treatment plan with your physician
or other healthcare providers about the purpose, potential risks and benefits of any test or procedure ordered
for you. If you have any concerns regarding any test or treatment recommended by your physician or other
healthcare provider, we encourage you to ask questions.
- PAYMENT AGREEMENT AND ASSIGNMENT- except as prohibited by any agreement between my insurance
company and Magnolia Family Medicine, or by federal or state law, I agree to be responsible for my copayment, deductibles or other charges for medical services not covered or paid by insurance or other third
party payers. I authorize Magnolia Family Medicine to file any claims for payment of any portion of the
patient bills and assign all rights and benefits to Magnolia Family Medicine. I further agree, subject to federal
or state law, to pay all costs, attorney fees, expenses and interest in the event Magnolia Family Medicine
takes action to collect because of my failure to pay in full all incurred charges.
By signing below, you are indicating that you intend that this consent is continuing in nature even after a specific diagnosis
has been made and treatment recommended, and that you consent to treatment at this office or any other satellite office
under common ownership. The consent will remain in effect until I withdraw my consent in writing.
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
MAGNOLIA FAMILY MEDICINE FINANCIAL POLICY
We are doing everything possible to hold down the cost of medical care. You can help a great deal by
eliminating the need for us to bill you. The following is a summary of our payment policy.
ALL PAYMENT ARE EXPECTED AT THE TIME OF SERVICE: Payment is required at the time services are
rendered unless other arrangements have been made in advance. This includes applicable copayments,
coinsurance and deductible payments for participating insurance companies. We accept cash, personal
checks (in-state only), Visa, MasterCard, Discover, And American Express.
THERE IS A SERVICE CHARGE FEE OF $30.00 FOR ALL RETURNED CHECKS
LATE FEES: Payment is required at the time services are rendered unless other arrangements have been
made in advance. This includes applicable copayments for payment prior to scheduling appointments.
THERE WILL BE A $30.00 MONTHLY LATE FEE CHARGE ON ANY BALANCE AFTER 30 DAYS. All accounts
more than 120 days past due will be transferred to a collections agency and you will be responsible for
all agency fees and would adversely affect your credit rating with the credit bureaus.
INSURANCE: We bill participating insurance companies as a courtesy to you. You must present your
most recent insurance card at the time of service. You are expected to pay your deductible/copayments
at the time of service in full. VERIFICATION OF BENEFITS IS NEVER A GUARANTEE OF PAYMENT; ALL
CLAIMS ARE SUBJECTED TO THE TERMS OF YOUR PLAN AFTER FILING YOUR CLAIM. If we have NOT
received payment from your insurance company within 45 days from the date of service, you will be
expected to pay the balance in full. You are responsible for all charges and all late fees. Your time of
service receipt includes all information necessary for submitting claims to your insurance company. We
bill secondary insurance companies if applicable.
MANAGED CARE: if you are enrolled on a managed care insurance plan (i.e. HMO) you must present
your most recent insurance card with our primary care physicians name on it. If you do not have it at the
time of service, we will reschedule your appointment for a later date. Referrals will be given only after
consultation with one of our doctors. You must receive a referral from our office before seeing a
specialist. NO retroactive referrals will be given.
OUT OF NETWORK We accept a variety of insurance plans, and due to the complexity of managed care
contracts, we suggest patients to verify our doctor's participation of IN NETWORK STATUS with their
insurance company prior to making the appointment at MAGNOLIA FAMILY MEDICINE.
REFUNDS Overpayments will be refunded upon written request within 30 days to the responsible party.
MISSED APPOINTMENTS/LATE CANCELLATIONS: Broken appointments represent a cost to us, to you
and other patients who could have been seen in the set aside for you. Cancellations are requested 24
hours prior to the appointment. We reserve the right to charge for missed/late- cancelled appointments
a minimum fee of $30. Abuse of scheduled appointments may result in the discharge from the practice
I have read and understand MAGNOLIA FAMILY MEDICINE FINANCIAL POLICY. I agree to assign
insurance benefits to Westwood Primary Care PLLC whenever necessary. I also agree that if it becomes
necessary to forward my accounts to a collection agency, I will be responsible for all collection fees.
