Consent to treatment 

besa Health

besa Health Technology, Inc. (“besa Health Technology”) is not a medical group but a Business Associate that has partnered with specific medical groups (collectively, “besa Health”) to bring healthcare services nationwide, as well as online with our telehealth solution.

Consumer Consents

NOTICE TO CONSUMER

Welcome to besa Health. At this point in your care, no specific treatment plan has been recommended, until we have had the opportunity to identify your needs. This consent form is simply to obtain your permission to perform the evaluation necessary to identify any condition that might require an appropriate treatment and/or procedure as part of your plan of care. You have the right to be informed about any condition identified and the options for recommended surgical, medical or diagnostic procedure to be used. You may then decide whether or not to undergo any suggested treatment or procedure, after being informed of the potential benefits and risks involved. This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By accepting and signing the consent below, you are indicating that you understand that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended, along with potential risks and benefits. This consent will remain fully effective until it is revoked in writing. You have the right at any time to ask additional questions or to discontinue or decline services. You have the right to discuss the treatment plan with your provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your provider, we encourage you to ask questions. We are not an Emergency Room and are unable to provide medical services for life-threatening and/or serious illnesses. If you believe you have a life-threatening and/or serious illness, please call 911 or go directly to an Emergency Room. besa Health providers include physicians, physician assistants, registered nurses and nurse practitioners. These providers are licensed by the appropriate applicable licensing bodies of the state they provide services in. All providers furnishing services to the undersigned are owners or independent contractors at besa Health.

CONSENT TO EVALUATION AND TREATMENT

I voluntarily consent to performance of medical services by besa Health. This may include medical evaluation, procedures and treatment. Such procedures may include, but are not limited to: IV placement, X-rays, wound repair, blood draw and incision and drainage of abscesses. Treatment modalities include oral, intravenous, intramuscular, subcutaneous and inhaled medications, fracture treatment including splints and slings, wound repair including bio- occlusive glue and sutures. I understand that medical care is not an exact science and that no guarantee or warrantee is being made as to my examination, treatment, result or outcome. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. However, I understand that doing so may hinder my treatment and/or medical outcome.

CONSENT TO USE AND DISCLOSE INFORMATION

I agree and consent to the use and disclose of my health information for the purpose of treatment, payment from third party payers, and other healthcare operations, such as the maintenance of medical records, communication of health information with other health professional who contribute to my care, and quality peer reviews and assessments.

ACCIDENTAL BODILY FLUID EXPOSURE TO HEALTHCARE WORKER

In the case of my bodily fluid exposure to a healthcare employee, I consent to testing, which may include, but not limited to, HIV or Hepatitis, to determine the presence of any communicable disease for the benefit of the exposed employee. I understand that these test results do not become a part of my medical record.

CONSENT TO PHOTOGRAPH

I grant permission for besa Health to take photographs, should the need arise, for purpose of my treatment during my health evaluation and treatment.

CONSENT TO TEXT

I grant permission for besa Health to send me text messages regarding wait times, my appointments, follow up questions, billing questions and attempts to collect payment should the need arise.

CONSENT TO RECORD

I grant permission for besa Health to record video and audio of my encounter with a provider. I understand that these recordings are to be used for quality assurance and to process in artificial intelligence to assist providers in clinical note taking.

PERSONAL VALUABLES

Although the facility will make all reasonable efforts in safeguarding my valuables, I understand that besa Health is not responsible for the loss or damage of personal valuables.

ASSIGNMENT OF INSURANCE BENEFITS

I assign besa Health all rights, title, and interest in any and all health insurance, including Medicare and/or health plan proceeds/benefits from any plan(s) arising from the provision of any goods and services provided by besa Health and/or physicians/healthcare providers thereof. At besa Health’s election, I also assign all of my rights and interest in all such insurance benefits or proceeds, including but not limited to the right to appeal any denial of benefits or to file any lawfully authorized lien necessary to secure payment from any third party or a third party’s Insurer. I understand that I am financially responsible for the services rendered by besa Health and agree to immediately remit all payments received from insurance for those services. I agree to cooperate with besa Health or its agent in collecting any such benefits. This assignment shall not obligate besa Health to file any appeal or perfect any such lien and nothing herein shall relieve me from direct financial responsibility for any charges not paid by an Insurer.

FINANCIAL RESPONSIBILITY

Copays, coinsurance, or self pay fees are due at time of service. besa Health only accepts credit cards as forms of payment. All remaining balances are due upon receipt of a patient invoice after your insurance has determined benefits processing your insurance claim, this may include deductible amounts or non-covered service balances.

I acknowledge that agreed upon payment are due at time of service including copays or Prompt Pay fees may be paid by credit cards (not cash or checks). I acknowledge that many insurers will only pay for services that they determine to be medically necessary and that meet other coverage requirements.

I understand that besa Health may not participate in all medical health insurance networks, and that health insurance coverage varies by region. I acknowledge and understand that if any of the services I receive are deemed out of network, unauthorized, or not medically necessary by my insurance carrier, then my insurance carrier may deny payment or pay for services rendered at a lower rate compared to those considered as “in-network.” As such, I may be billed up to 100% of the standard fees that besa Health bills for such services. I am aware that besa Health will provide me with the anticipated total charges prior to rendering services and attempt to courtesy bill my insurance carrier after my visit. I understand that my final bill will be adjusted based on total treatment costs and insurance benefits. Should my account be referred to an attorney or collection agency, I agree to pay actual attorney’s fees and collection expenses. All delinquent accounts shall bear interest at twelve percent per annum, not to exceed the maximum amount permitted by law.

I certify that I have read the foregoing, and am the patient, the patient’s legal representative or duly authorized by the patient as the patient’s agent to execute this Consent and to accept its terms.

CREDIT CARD AUTHORIZATION

I understand that if I have provided my insurance information during my visit today, our billing team will send a claim to my insurance company shortly after my visit. Once the claim is successfully processed, my insurance company will send besa Health a statement with the amount I owe. If I have a remaining balance, I will receive a statement via email with the amount I owe. I understand that besa Health will charge the credit card I have left on file.

The date besa Health charges the card will be written on the credit card statement. If I would like to make other arrangements to pay off my balance or have questions regarding the statement, I will contact besa Health before the date on my statement. The besa Health billing team’s email address and phone number will be listed on the statement.

By signing this form, I am consenting to leave a credit/debit/HSA or FSA card on file with besa Health. My information will be stored using the same encrypted, secure software used to store my medical records. I am also consenting to have my credit/debit/HSA or FSA card charged for any remaining balance I may owe.

ELECTRONIC COMMUNICATION CONSENT

I consent to receive email communications from besa Health and request online access to my profile to do things such as make or cancel appointments.

I grant permission for besa Health to send me text messages and emails regarding wait times, my appointments, follow up questions, billing questions and attempts to collect payment should the need arise.

I hereby consent and state my preference to have all staff at besa Health communicate with me by email or standard SMS messaging regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, patient satisfaction surveys and billing.

I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my medical care might be intercepted and read by a third party.