Consent for Treatment

Medical care at Hilltop Medical Clinic requires a relationship between the Patient, the Providers, the Clinic Staff, the Clinic Managers, and the Clinic Owners. The relationship requires trust and mutual respect.  In addition to the policies noted below, signing this form authorizes the medical providers at the Clinic, to take a history and perform a medical exam in order to diagnose and develop a treatment plan.

Scope of Treatment

• Hilltop Medical Clinic provides urgent care services.  This is different from a medical home or primary care provider, who is responsible for preventive care and management of chronic medical conditions.
• We encourage all patients to have a primary care provider.
• We recognize that that is not always possible, so patients use HMC for their primary care services.  Of course, we do not want your medical care interrupted, but you are responsible for keeping follow up appointments and preventive care services.  HMC does not have a system to remind patients of appointments.

Clinic Policies

• Examination of sensitive or personal areas will be in the presence of a chaperon. A family member is not a legal chaperon.
• HMC and its providers will not prescribe medications for assisted suicide. This requires an ongoing relationship with a primary care provider or hospice provider.
• HMC does not provide medical marijuana prescriptions.
• Prescriptions of controlled medications require a picture ID. Prescriptions for patients under 18 must be released to the parent or legal guardian.
• We are required by law to run a CURES Par on all patients receiving controlled medications.
• Aggressive behavior will not be tolerated and will result in an immediate dismissal from the practice.
• Dismissal from the practice. An explanation or justifications is not required. We will notify you by mail and continue to provide medical care for 15 days.
• HMC is a nondiscriminatory environment, however, genetic and therefore racial and cultural differences are used to make medical decisions based on scientific studies that support this approach.
• Animal bites are reported as required by law.
• HTMC does not bill third party claims (motor vehicle accidents, injuries sustained while   shopping, homeowners liability claims, etc.).   Payment is expected at the time of service and a billing/receipt will be issued to you for billing purposes.
• HTMC is not in network with HMO plans, United Healthcare, GEHA, UMR or Cigna.
• HTMC does not accept or bill ANY Medi-Cal, Medicaid or other state sponsored health plans. This applies nationwide. If you are covered by any of the above mentioned plans, and you choose to be seen in our office, by signing this form you are accepting financial liability for all services provided.

Patient

• You have the right to obtain a second opinion, refuse treatment, or change your mind without judgment or pressure.
• You are encouraged and requested to ask questions in order to understand the diagnosis and treatment options for your medical problem.
• Consent forms for minor procedures and injections are not required for treatment. Receiving treatment is acknowledgment that you understood the risks and benefits and agreed to proceed.
• Results of sensitive tests cannot be sent by text, e-mail or phone voicemail.  You must call in for the results.

Refunds

• Our office will automatically generate a refund for $75.00 or more when due, once all visits are processed and payment received from insurance. If you are due a refund less than $75.00, we will leave it on your account for future use. You can call and request your refund be issued if you prefer.

Provider

• Providers frequently have to ask sensitive, personal questions to diagnose medical conditions. Parents should excuse themselves from the exam room, if they do not want to hear the answers.
• Providers are not obligated to provide medical care or services that they feel are not warranted.
•  Providers are required by law to report episodes of complete loss of consciousness to the health department.
• Providers are required to report any suspected episode of child or spousal abuse to the police.

Medical Records

• Medical Records will be maintained in electronic format for the duration of time required by California State law.
• You may obtain a copy of your records at any time in a printed copy. Your first copy is Free and charges apply for additional copies of your medical records.
• Employees at HMC may contact and disclose medical information to the persons listed as guardians and emergency contacts, without additional notification or permission from you, the patient.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Hilltop Medical Clinic West ♦ 2123 Eureka Way ♦ Redding, Ca  96001 ♦ (530)246-4629

I understand that under the Health Insurance Portability and Accountability Act of 1996, (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used for the following:

● To conduct, plan, and direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment, directly and indirectly.

● To obtain payment from third-party payers, including use as a means by which an insurance or other payer can verify that services billed were actually provided.

● To conduct normal healthcare operations such as quality assessments and reviewing physician competence for physician certifications.

I have been provided with Hilltop Medical Clinic West’s Notice of Privacy Practices, which document contains a more complete description of the uses and disclosures of my health information.  I understand that Hilltop Medical Clinic West has the right to change its Notice of  Privacy Practices from time to time and that I may contact Hilltop medical Clinic West at any time at the address above and obtain a current copy of the Notice of Privacy Practices.  In addition, Hilltop Medical Clinic West will post a copy of any revised Notice of Privacy Practices in its lobby for my review.

I understand:

● That I may request in writing that Hilltop Medical clinic West restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that Hilltop Medical Clinic West is not required to agree to my requested restrictions, but if Hilltop Medical Clinic West does agree it is bound to abide by such restrictions.

● That I have the right to review the notice prior to signing these Acknowledgement, and also the right to revoke this Acknowledgement in writing except to the extent that Hilltop Medical Clinic West has already taken action in reliance thereon.

● That I personally must sign a medical records release authorization before my specific health information will be released to anyone by Hilltop Medical Clinic West.

● That I may refuse to sign this consent Form.  However, if I do so, Hilltop Medical Clinic West is NOT required to see and/or treat me as a patient.

 

If you request restrictions on the use or disclosure of your health information, then indicate your desired restrictions here, and verbally notify the receptionist:

 

X_________________________________________

SIGNATURE OF PATIENT/LEGAL GUARDIAN

 

I attempted to obtain the patient’s signature in acknowledgment of receipt of the Notice of Privacy Practices, but was unable to do so as documented below:

Date:_____________  Initials:_______________

Reason:__________________________________________________________________________________

 

Patient’s Responsibilities in Work Related Injuries

As of 9/1/2017, we terminated our work comp MPN agreements.  We may accept a limited amount of Work Comp cases at the discretion of the physician on duty each day. 

IF you are being evaluated at Hilltop Medical Clinic (HMC) for a work related injury the workers compensation injury program has a reputation for being contentious and frustrating, so effective communication is essential.

HMC, an urgent care clinic, is available to see injured workers for new, acute work related injuries.  The injury must fall within our scope of practice and will extend for 45 days or the acute phase of the injury.

You are obligated to see the Employer’s provider for 30 days, unless the Employee has made arrangements in advance of the reported injury to see their Primary Care provider.  After 30 days, the Employee is free to transfer their care to anyone within their network.

After 30 days, if your injury is not healing or responding to treatment and the claim cannot be closed, HMC will send a report and a request to extend treatment into the sub-acute management phase, which is 180 days. The majority of claims are closed within this time. If the extension agreement is not reached, you will be notified as soon as possible, so you can contact the adjuster and make other continue care arrangements.

On the first visit, it is essential to identify and agree to the areas that have been injured, as this will not be allowed to change without a formal request to the adjuster. It will appear on your initial discharge papers.

As the injured party, you are the one at risk to have residual changes to your health. Your employer and the insurance companies responsibilities are to provide medical care that will restore your functional capacity and allow you return to work.  Therefore,  it is in your best interest to do everything possible to improve your health, even if it is not directly related to the injury. For example, if you smoke you should try to stop, because smoking delays healing of bone and connective tissues. Contact your Primary Care provider for help in these important areas, as the workers compensation insurance company is only obligated to provide care to the injured area.

Return appointments are essential to keep your claim current, to monitor progress, to change treatment plans, to renew medications and to update work restrictions.  The return date will be on the discharge sheet that you receive as you complete your visit.  It is your responsibility to call and change the date, if you cannot make the appointment or miss one.  Missed appointments may interrupt your financial support, if you are off work or on limited duty or result in you being return to full-duty 48 hours after the missed appointment.

At each visit your functional status will be evaluated to determine your work status.  The current recommendations will be forwarded to your employer.  You will receive a copy on your discharge papers.  Workers Compensation rules require us to describe your functional status independent of your current position or responsibilities.  The Employer then uses this information to decide if there is appropriate limited duty that can accommodate the limitations.  Patients on limited duty frequently are not returned to their customary positions.

Remain in contact with your employer. It is your responsibility to protect your relationship with your employer and your position. Each office visit at HMC will include a work status report for you and your employer. These reports are an inexact science and require the addition of  ‘common sense’ on both parties. A simple change, after a conversation between you and your employer, may allow you to return to work on modified duty. This is the best way to protect your position in the Company.

HMC is dedicated to providing you with professional medical care to help you restore your health after an injury. Thank you for your trust.

Workers Compensation Office Policies

As of 9/1/2017, we terminated our work comp MPN agreements.  We may accept a limited amount of Work Comp cases at the discretion of the physician on duty each day. 

If your case is accepted by Hilltop Medical Clinic then we will be designated as the Primary Treating Physician (PTP) for your worker’s compensation injury. Your PTP will diagnose, treat and will decide the best work status for your specific injury. Each time you are seen at the clinic, you must wait for the nurse to check you out after seeing the doctor. The nurse will give you your work status, the date of your next visit and any medications that we can dispense here. Since we have no narcotics, you may need to go to the pharmacy for prescriptions that are not in our pharmacy formulary. If the doctor gives you work restrictions, you are expected to speak to your employer as soon as possible to see if your employer can accommodate these restrictions. It is your responsibility to remember your recheck date at the clinic. Not returning on the correct date may affect your worker’s compensation benefits and may delay your checks from your insurance company. Your employer cannot accommodate the restrictions they may decide to keep you off work.
Chronic injuries: It is our goal of our physicians to help you improve as much as possible and return to work as soon as possible. Sometimes your injury may prevent you from returning to your normal work for quite some time. If you cannot improve to your pre-injury status, or if you have permanent restrictions, the PTP may designate you Permanent and Stationary in regards to your injury. Once this is done, you will need to have your family doctor or another physician see you for any treatment and follow-up. Hilltop Medical Clinic will not continue to follow you for this injury and non-acute problems.
Denied Claims: If your claim is denied by the insurance company, it will be your financial responsibility to pay the clinic for any bill you incurred during your treatment for this injury. You will also be responsible for any treatment by other healthcare professionals incurred for therapy you may have received.
Forms: The doctor will complete required forms for your work comp injury free of charge. There will be a $15 charge for any other forms related to your disability or your own personal finances. It will be your responsibility to pay this charge at the time the forms are completed.
You are ONLY to discuss your work comp injury with physician: Your employers contracted work comp insurance may be liable today for your injury that you are being seen for. If you choose to discuss unrelated work comp illness/injuries with the physician today you will be asked by the receptionist to provide private insurance and payment for that portion of your visit that is unrelated to your work comp injury. Some unrelated illness/injury examples are blood pressure, insomnia, sore throat, rash, pains in other areas not related to your work comp injury.
Physicians: Your case may be followed by different physicians. Your care will be documented in our system so that any physician will be able to continue treatment. You will see the physician that we schedule you for on your return visits. You may not be able to request the same physician for repeat visits.
OWCP CLAIMANTS: It is your responsibility to provide our office with the CLAIM number as soon as you receive it. You will receive this information with your acceptance letter on your claim. If the proper paperwork is not completed/filed and we do not receive the claim number, you will be financially responsible for any and all medical bills incurred at our office and any office we have referred you to for treatment on this work related injury.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

By law Hilltop Medical Clinic cannot release all your medical information concerning your injury or industrial accident without your written authorization. To ensure all aspects of your injury are disclosed to the insurance company and to your employer it is important for you to give Hilltop Medical Clinic the authority to release all this information. Each time you come to the clinic for a recheck, Hilltop Medical Clinic will send information to both the insurance company and your employer about your visit, treatment and work status.
I hereby authorize Hilltop Medical Clinic to furnish to my insurance company, employer, Attorney or legal representative, all information concerning my industrial injury or accident. This includes how I injured myself, medical history, treatment and work status.
ANY PERSON WHO MAKES OR CAUSES TO BE MADE ANY KNOWINGLY FALSE OR FRAUDULENT MATERIAL STATEMENT OR MATERIAL REPRESENTATION FOR THE PURPOSE OF OBTAINING OR DENYING WORKERS COMPENSATION BENEFITS OR PAYMENTS IS GUILTY OF A FELONY.

Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.