Consent Form Treatment

Consent For Treatment

The undersigned patient and/or authorized relative/legal guardian hereby consents to authorize Broward Community & Family Health Centers, Inc., its facilities or treatment centers and affiliated physicians, dentists, surgeons, and other medical personnel, to administer and perform any and all medical examinations and treatments that may now or during the course of the patient’s care be necessary or advisable and further agree to hold Broward Community & Family Health Centers, Inc., its affiliates and medical personnel, harmless for all such medical treatments. I understand that Broward Community & Family Health Centers, Inc., maintain medical records on my behalf, which contain health information and opinions about my health, substance abuse, mental health, social and other history, symptoms, examinations and test results, diagnosis, treatment/services and/or plans for future care, protected under 42 U.S.C. 290dd-2 and 397.501, Fla. Stat., as well as treatment of mental illness under 394.4615, Fla. Stat., unless otherwise provided and only to such extent found in the referenced regulations. I voluntarily authorize, give my permission, and allow use and disclosure (including paper, oral and electronic interchange) of ALL MY HEALTH INFORMATION including information about sensitive conditions (if any) such as drug, alcohol, or substance abuse, psychological, psychiatric or other mental impairment(s) among the clinical team overlooking my care. 

Method of Payment

Patient is asked, “how do you intend to pay for your treatment?” and selects the options that apply from the list below: 

• Self
• Medicare
• Private Insurance
• Other

[Patient Types Their Name] I agree to be responsible for  payment for all charges incurred for my medical care at Broward Community & Family  Health Centers, Inc. facility or treatment center and/or its affiliates. If I have private insurance, I agree to be responsible for paying the deductibles, co-payments and for any other non-covered services rendered. 

[Patient Types Their Name] Medicare currently covers me. I agree to be responsible for the charges associated with meeting any Medicare deductible and the 20% co-payment on all Medicare charges. I further agree to be responsible for paying the supplemental insurance deductibles and/or co-payments and/or for any other non-covered services rendered. 

Patient Signature

I authorize the release of any medical information, including any HIV (AIDS), mental health and/or substance abuse test (s) and results necessary to process all health insurance claims (current and supplemental) to Medicare, Medicaid, insurance company (s), physicians (s), and/or other health care facility or health care providers to whether this facility may refer the patient. I further agree to release Broward Community & Family Health Centers, Inc. , its facilities, treatment centers, and it’s affiliated personnel from all legal responsibility and/or liability that may arise from the release of such records and waive all rights I have to preserve their confidentiality.