Patient Information

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Marital Status

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Race

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Ethnicity

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Insurance

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Living Information

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Employment Information

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PATIENT CONSENT FOR HEALTH CARE

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PATIENT CONSENT FOR GENERAL PRIMARY, SPECIALTY, AND TELEHEALTH CARE FORM

CONSENT FOR MEDICAL TREATMENT

I and/or my dependent, as named above, voluntarily present to St. Mary’s Health Wagon, Inc., a Virginia nonstock corporation d/b/a the Health Wagon, (“Health Wagon”), and consent to treatment of the Nurse Practitioners, Physicians, Nurses, Students, and other medical care providers of the Health Wagon (the “Health Care Professionals”) and whomever the Health Care Professionals may designate as their assistants, associates, treating health care professionals and patient care staff to provide my care. Such care may include, but is not limited to, diagnostic procedures and the administration of medications considered advisable in my diagnosis, treatment, and course of care. I acknowledge that no guarantee can be made or has been made as to the results of treatments or examinations and I understand that all medical treatments contain inherent risks. I further authorize the Health Care Professionals of the Health Wagon to examine and/or treat me and/or my dependent, as named above.

SERVICE LIMITATIONS

Services at the Health Wagon are provided by nurse practitioners, medical doctors, volunteer health care providers and medical students; therefore, we are unable to provide some services. We do not provide any of the following services: controlled substances and contraceptives (birth control).

NOTICE OF DEEMED CONSENT FOR HIV, HEPATITIS B OR C TESTING

The Health Wagon is required by § 32.1-45.1 of the Code of Virginia (1950), as amended, to give you the following notice:

If any Health Wagon healthcare professional, worker or employee should be directly exposed to your blood or body fluids in a way that may transmit disease, your blood will be tested for infection with human immunodeficiency virus (HIV), as well as for Hepatitis B and C. A physician or other health care provider will tell you the result of the test. Under VA Code § 32.1- 45.1(A), you are deemed to have consented to the release of the test results to the person exposed.

If you should be directly exposed to blood or body fluids of a Health Wagon healthcare professional, worker or employee in a way that may transmit disease, that person’s blood will be tested for infection with human immunodeficiency virus (HIV), as well as for Hepatitis B and C. A nurse practitioner, physician or other health care provider will tell you and that person the result of the test.

HIV TESTING

If HIV testing is performed, you will be told ahead of time, be given information about the test, and allowed to decline testing. All results will remain confidential except as allowed by law.

I understand that this consent will remain in effect as long as my dependent or I receive care from the Health Wagon or until I withdraw it.

RECEIPT OF THE NOTICE OF PRIVACY PRACTICES

I acknowledge that I can receive Notice of Privacy Practices from the Health Wagon at any time by putting the request in writing.

NO-SHOW POLICY

To help patients of the Health Wagon, we will call to confirm your appointment. We understand that sometimes you need to cancel or reschedule. If you cannot come to your appointment, please cancel or reschedule as soon as possible. By cancelling your appointment early, we can help other patients who need to be seen. A “no-show” is someone who misses a scheduled appointment without cancelling in advance of 24 hours. Not showing up to a scheduled appointment inconveniences those individuals who need access to medical care in a timely manner. If you need to cancel or reschedule, please call the Health Wagon at 276-328-8850 at least 24 hours in advance. If you are sent to voicemail, please do not hang up. Leave the following information: your name, telephone number, reason for cancellation, and date and time of your appointment. If you do not call to cancel and do not show up for your scheduled appointment, you are considered a no-show. If you arrive 20 minutes after your appointment time, you are considered a no-show; and a medical provider will decide whether to reschedule your appointment or see you that day. If you are a no-show, you will be charged a $10 reinstatement fee before we can schedule you another appointment. After (3) three no-show's all services will be suspended.

RECORD KEEPING

I understand that medical records will be retained for six years after the date of the last visit or for five years following patient's death. In the case of a minor, the record will be retained ten years after the last visit or for five years after age 18, whichever comes later. I authorize the Health Wagon to release records necessary to support the application for payment by Medicare, Medicaid, and other health care benefits. I request the third-party payer to pay any authorized benefits to the Health Wagon on my behalf. I understand that this consent will remain in effect as long as my dependent or I receive care from the Health Wagon or until I withdraw it.

ASSIGNMENT OF INSURANCE BENEFITS AND PAYMENT GUARANTEE

In consideration of services provided, I hereby assign and transfer to the Health Wagon any and all rights, which I have against insurance companies or third party payers, for payment of charges for services provided by The Health Wagon to me or to one of my dependents. I authorize said payments to be applied to any unpaid balance for which I am responsible.

SPECIAL INSTRUCTIONS:

Please provide any special instructions or things that the Health Wagon should know before performing your medical examination:textrequireddb save

I understand that I have the right to revoke this Consent by written notice to The Health Wagon.


Date: 4/14/2022

Time: 12:48 AM

Signature of Patient, Parent/Guardian, or Person Acting in Loco Parentisrequired
Tap to Sign

PRESCRIPTION CONSENT AND PRESCRIPTION MONITORING

By signing below, you are agreeing that your provider at the Health Wagon may request and use your prescription medication history from other healthcare providers, Virginia’s Prescription Monitoring Program, and/or third-party pharmacy benefit payors for treatment purposes. You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services. You also have a right to receive a copy of this form after you have signed it. This consent for will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not have an effect on any actions taken prior to receiving the revocation. Understanding all of the above, I hereby provide informed consent to the Health Wagon to enroll me in the eScribe program (when applicable) and request prescription history by verifying with pharmacy or utilizing Virginia’s Prescription Monitoring Program. I hereby agree to the statement and policy above and will not ask my primary care provider or any other medical professional for controlled substances.

I understand that I have the right to revoke this Prescription Consent by written notice to the Health Wagon.


Date: 4/14/2022

Time: 12:48 AM

Signature of Patient, Parent/Guardian, or Person Acting in Loco Parentisrequired
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THE PHARMACY CONNECTION (TPC)

By signing below, you authorize the Health Wagon to serve as your advocate in ordering medications through TPC. In doing so, you authorize TPC Case Workers to sign authorization forms, order medications and order medication refills on your behalf. There is no cost for most medications; however, not all medications can be ordered at no cost and may have to be purchased by the patient at a discounted price.


Date: 4/14/2022

Time: 12:48 AM

Signature of Patient, Parent/Guardian, or Person Acting in Loco Parentisrequired
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RELEASE AND USE OF PATIENT INFORMATION

I authorize the release of my medical records, information, treatment and advice, and specific health information to:

  1. MY TREATING HEALTH CARE PROFESSIONAL on staff at the Health Wagon and to the staff, agents of another healthcare facility in the event of my transfer to another facility, and to my primary care health care professional or any referred consultants for follow up care;
  2. AN EMPLOYER who requests services, which may include your personal medical history, physical, laboratory and diagnostic tests, and drug screenings (including the presence of drugs, alcohol or marijuana);
  3. INSURANCE COMPANY or other third-party payer and their agents as well as any review organization or government agency for the purpose of determining eligibility and available benefits, obtaining payment for services provided, and insuring government compliance; and
  4. EDUCATIONAL OR SCIENTIFIC INSTITUTIONS, authorized health care professionals in training, internal quality improvement, risk management and legal counsel when it is judged that my ongoing medical care, medical research, quality improvement, healthcare education or science will benefit; for any purpose authorized by law.

I further understand that the Health Wagon expressly reserves the right to and may disclose information to others who may not be on the list above and to use information in a manner not specifically set forth above, if and to the extent not restricted by Health Insurance Portability and Accountability Act of 1966 (“HIPPA”), including, but not limited to disclosures for treatment, payment or healthcare operations in accordance with the Health Wagon Notice of Privacy Rights provided to me.

I understand that if I refuse to authorize access to my records for coordination of care, there may be an adverse effect on my treatment or care. I understand this information may contain my personal medical history, physical conditions, treatments (if necessary), radiographic and laboratory results, and more specifically results in reference to alcohol/drug abuse, mental health, or infectious disease (including human immune-deficiency virus, hepatitis, or other infectious diseases).

I understand that I have the right to revoke this Authorization by written notice to the Health Wagon.


Date: 4/14/2022

Time: 12:48 AM

Signature of Patient, Parent/Guardian, or Person Acting in Loco Parentisrequired
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PUBLICITY CONSENT WAIVER AND RELEASE AGREEMENT

THIS PUBLICITY CONSENT WAIVER AND RELEASE AGREEMENT (this “Agreement”) is made on 4/14/2022 by and between St. Mary’s Health Wagon, Inc. d/b/a The Health Wagon (the “Company”) and [ First Name ] [ Last Name ] (the “Individual”).

WHEREAS, to promote its business, the Company desires to use and publicize the name, likeness, and other personal characteristics of the Individual for use in (i) advertisements and promotional materials, (ii) newsletters, magazines, journals and other publications, (iii) posters and prints, (iv) websites and other online usage, and (v) other related media (the “Permitted Uses”);

WHEREAS, the Individual desires to permit, authorize, grant, and license to the Company and its affiliates, successors, and assigns, and the employees, officers, directors, and agents of each and all of them (“Authorized Persons”), the rights to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use the Individual’s name, image, likeness, appearance, voice, and other personal characteristics and all materials created by or on behalf of Company that incorporate any of the foregoing (collectively "Materials") and to use such Materials for the Permitted Uses.

NOW THEREFORE, in consideration of the promises, and upon the terms and conditions hereinafter set forth, the parties agree as follows:

  1. Consent to Company Right to Use Materials. The Individual hereby consents, permits, authorizes, grants, and licenses to the Company’s the use of the Individual’s Materials in perpetuity for the Permitted Uses. Individual acknowledges that Individual shall be entitled to no monetary compensation for any use of Individual’s Materials for the Permitted Uses, regardless of whether Company generates any revenue from use of Individual’s Materials.
  2. Waiver and Release. The Individual hereby irrevocably waives all legal and equitable rights relating to all liabilities, claims, demands, actions, suits, damages, and expenses, including but not limited to claims for copyright or trademark infringement, infringement of moral rights, libel, defamation, invasion of any rights of privacy (including intrusion, false light, public disclosure of private facts, and misappropriation of name or likeness), violation of rights of publicity, physical or emotional injury or distress, or any similar claim or cause of action in tort, contract, or any other legal theory, now known or hereafter known in any jurisdiction throughout the world (collectively, “Claims”) arising directly or indirectly from the Authorized Persons’ exercise of their rights under this Agreement or the production, exhibition, exploitation, advertising, promotion, or other use of the Materials, and whether resulting in whole or in part by the negligence of Company or any other person, covenant not to make or bring any such Claim against the Company or any Authorized Persons, and forever release and discharge the Company and Authorized Persons from liability under such Claims. Individual understands that Company is relying on this Agreement and will incur significant expense in reliance on this Agreement.
  3. Right to Modify. The Company shall have the sole and exclusive right to make such modifications and/or alterations to any Individual’s Materials as the Company may, in its sole discretion, deem to be desirable. In addition, the Company shall have all other rights customarily associated with ownership of such Materials, including, but not limited to, the right to choose the design layout, the number of copies of each Materials to be produced, the manner, style, format and media of printing or production each Materials and all matters relating to the use, promotion, and advertising of the Materials. The Individual agrees that the Company may, but shall not be required to, use the Individual’s name in connection with the Materials.
  4. Company Right to Use Materials. Individual affirms, acknowledges, and agrees that Company shall be the exclusive owner of all rights, including copyright, in the Materials. Individual hereby irrevocably transfers, assigns, and otherwise conveys to Company the Individual’s entire right, title, and interest, if any, in and to the Materials and all copyrights and other intellectual property rights in the Materials arising in any jurisdiction throughout the universe in perpetuity, including all registration, renewal, and reversion rights, and the right to sue to enforce such copyrights against infringers. The Company shall have the exclusive and unconditional right to use an unlimited number of copies of the Materials without payment, royalty or remuneration of any kind to the Individual.
  5. Representations of Individual. The Individual represents and warrants to the Company: (A) that the Individual is over the age of eighteen (18) years, or other applicable jurisdictional age of contractual competency, or, in the alternative, that this Agreement has been signed by the Individual’s parent or guardian, and (B) that the opinions contained in the Individual’s Materials are the opinions solely of the Individual and not of any other person or entity, including but not limited to Individual’s employer.
  6. Miscellaneous. This Agreement constitutes the sole and entire agreement of the parties with respect to the subject matter contained herein and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, both written and oral, with respect to such subject matter. Individual has not relied on any statement, representation, warranty, or agreement of Company or Authorized Persons, including any representations, warranties, or agreements arising from statute or otherwise in law, except for the representations, warranties, or agreements expressly contained in this Agreement. If any term or provision of this Agreement is invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability will not affect any other term or provision of this Agreement or invalidate or render unenforceable such term or provision in any other jurisdiction. Company may assign this Agreement and its rights hereunder, in whole or in part, to any party. This Agreement is binding on and inures to my benefit and the benefit of Company and our respective heirs, executors, administrators, legal representatives, successors, and permitted assigns. All matters arising out of or relating to this Agreement shall be governed by and construed in accordance with the internal laws of the Commonwealth of Virginia without giving effect to any conflict of law provisions or rules. Any claim or cause of action arising under this Agreement may be brought only in the federal and state courts serving Wise County, Virginia, and I hereby irrevocably consent to the exclusive jurisdiction of such courts.

THIS AGREEMENT PROVIDES COMPANY WITH YOUR ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER, AND RELEASE OF LIABILITY, ALLOWING COMPANY TO PUBLICIZE AND COMMERCIALLY EXPLOIT YOUR NAME, LIKENESS, AND OTHER PERSONAL CHARACTERISTICS AND PRIVATE INFORMATION AS SET OUT ABOVE. BY SIGNING, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS AGREEMENT AND THAT YOU ARE GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE COMPANY.


Date: 4/14/2022

Time: 12:48 AM

Signaturerequired
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I am the parent or legal guardian of the minor named above. I have the legal right to consent to and, by signing below, I hereby do consent in all respects to the terms and conditions of this Publicity Waiver and Release and agree that both the minor and I shall be bound by all of its terms and conditions.


Date: 4/14/2022

Time: 12:48 AM

Parent or Legal Guardian Signaturerequired
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DISCLOSURE AUTHORIZATION

I permit the Health Wagon, their providers, nurses and other personnel to discuss health information, in-person or by telephone, with the following individuals involved in my medical care:

Nametextoptionaldb save
Relationshiptextoptionaldb save
Contact Informationtextoptionaldb save
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Relationshiptextoptionaldb save
Contact Informationtextoptionaldb save
Nametextoptionaldb save
Relationshiptextoptionaldb save
Contact Informationtextoptionaldb save
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Relationshiptextoptionaldb save
Contact Informationtextoptionaldb save

Please select one:

I authorize the Health Wagon to leave a detailed message on voice mail or other recording associated with the following authorized phone number: [ Phone (Digits Only) ] .
I DO NOT authorize the Health Wagon to leave a detailed message on my voicemail or other recording. I acknowledge that by choosing this option that I, the Patient, assume full responsibility for contacting the Health Wagon for the results of all testing.

Release of this information under this document is not limited to verbal communications and can include telephone, text, email, Web Portal messenger, Facebook Messenger, Instagram Messenger, Facetime, or other audio, video, or digital communication platform.

I understand that the information a person receives may be disclosed and no longer protected by Federal privacy regulations. I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment. I understand I can rescind this authorization at any time. If, at any time, I do not want communication to be permitted between the Health Wagon and any of the individuals named above, I must notify my health care provider by calling 276-328-8850. The Health Wagon will not be liable for any communications that were permitted by this form and that were made prior to this notification.

I also understand that the information specified above may contain information related to treatment for drug and or alcohol use, for psychiatric/psychological and/or medical conditions, or HIV test results or diagnosis. I am including this type of information to be released in association with this type of authorization.


It is my desire that information in my (please mark the appropriate record (s)) indicated below is to be released as a result of this authorization:

in patient record
clinic record
emergency record
ambulatory testing

Check all that apply:

Face Sheet
Laboratory Reports
Therapy Reports
History & Physical
Operative Reports
Emergency Treatments
Discharge Summary
Pathology Reports
Consultation Reports
Provider Progress Notes
Radiology Reports
Providers Orders
Other
If Other, please specifytextoptionaldb save

You acknowledge that in the event of a critical episode or if you are unable to give your authorization due to the severity of your medical condition, the law stipulates that the above authorization rules may be waived.


Date: 4/14/2022

Time: 12:48 AM

Signature of Patient, Parent/Legal Guardianrequired
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Date: 4/14/2022

Time: 12:48 AM

Signature of Person Obtaining Consentoptional
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I would like to get a copy of this document. I confirm my email address is spelled correctly.
I agree to Waiver Master Terms & Conditions and Privacy Policy available at waivermaster.com/terms.html and waivermaster.com/privacy.html.

By clicking/tapping/touching/selecting or otherwise interacting with the "Submit" button below, you are consenting to signing this Document electronically. You agree your electronic signature ("E-Signature") is the legal equivalent of your manual signature on this Document. You consent to be legally bound by this Document's agreement(s), acknowledgement(s), policy(ies), disclosure(s), consent term(s) and condition(s). You consent to be legally bound by Waiver Master's policies, terms and conditions available at waivermaster.com/terms.html and waivermaster.com/privacy.html . You agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You may request a paper version of an electronic record by writing to us. We reserve the right to charge a reasonable fee for the production and mailing of a paper version of the record. Your current valid email is required for all communications.




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