Executive Urgent Care - New & Existent
Thank you. One last thing...
You will need to scroll down below and sign at the bottom of our terms below to complete.
Our summary of consent, terms and policies:
Please sign below to agree to the following terms, consent, and policies:
WHAT IS TELEMEDICINE?
Telemedicine (also sometimes called tele health) services are a way to deliver healthcare services locally to a patient when the healthcare provider is located at a distant site. Telemedicine is generally defined as the use of electronic information and communications technology to exchange medical information from one site to another site to provide medical or surgical treatment to a patient and/or to participate in the medical diagnosis of, or medical opinion or medical advice to, a patient.
When a healthcare provider believes a patient may benefit from the use of telemedicine services, telemedicine can maintain a continuity of care with the provider and facilitate patient self-management and caregiver support of the patient. Telemedicine services often provides a broader access to medical care, eliminates transportation concerns, and increases comfort and familiarity for patients and their families when located in their own homes or other local environments.However, telemedicine uses new communications technology for which there is little research supporting its effectiveness.
For example, telemedicine services may not be as complete as in-person healthcare services because the healthcare provider will not always be able to observe subtle non-verbal communications such as a patient's posture, facial expression, gestures, and tone of voice.Telemedicine may transfer medical information through the use of interactive, real-time audio/visual technology (for example, video conferencing) or electronic data interchange (for example, computer-to-computer exchanges), or it may transfer medical information through the use of store-and-forward technology (for example, emails). While precautions are taken to secure the confidentiality of telemedicine services, the electronic transmission of medical information can be incomplete, lost or otherwise disrupted by technical failures.
Additionally, despite such measures, the transmission and storage of medical information can be accessed by unauthorized persons, causing a breach of the patient's privacy.
I read and understand the information provided in this document.
I discussed any question I had with my doctor and all of my questions were answered to my satisfaction.
To our valued patients,
Due to the changing landscape of medical care and concerns over improper prescribing and overuse of narcotic pain medications, Executive Urgent Care will no longer issue prescriptions for chronic pain medications or other controlled substances that are being written by primary care or specialty providers.
These medications must be managed by your specialist or primary care provider. If your primary care or specialty provider is unable to see you and is willing to approve EUCIW writing you a short-term prescription until that provider can schedule a face-to-face visit with you, have the provider call EUCIW and speak to our office staff or provider on duty.
EUCIW will do all we can to assist in writing a short-term prescription. This will be on very limited basis, and will not be construed as routine practice.
We urge patients to schedule appropriate and timely appointments with their primary care or specialty providers to facilitate ongoing management of chronic medication needs.
We appreciate your understanding and look forward to caring for any of your other urgent care needs.
The Physicians, Providers and Staff of Executive Urgent Care
Here at Executive Urgent Care of Indian Wells, we are committed to providing our patients with quality medical care and to avoid any misunderstandings, we have created this financial policy to clearly outline the patient and practice financial responsibilities.
OUT OF NETWORK & NON INSURED
You expressly consent and agree that, in order to discuss or service your account(s) (the “Accounts”) or to collect amounts you may owe Executive Urgent Care, and its officers, agents, affiliates, employees, and any affiliated or associated service providers and any third-party debt collection agency associated therewith (collectively, “We”) may contact you by telephone at any telephone number associated with the Accounts, including wireless telephone numbers, which could result in charges to you. You expressly consent and agree that We may also contact you by sending text messages, emails, using any email address you provide to us, or by pre-recorded or artificial voice or voice messages, automatic dialing methods, systems, or devices, and pre-recorded or artificial voice prompts at any telephone number associated with the Accounts, including wireless or mobile telephone numbers, regardless of whether you incur charges as a result.
Our practice firmly believes that a good patient-provider relationship is based upon understanding and good communication. If you have any questions or concerns please feel free to talk to our staff. We are here to help you. Your signature below confirms that you have read and understand this financial policy.
I authorize the use and/or disclosure of my protected health information as set forth below:
74-785 Highway 111, Suite 100
Indian Wells, CA 92210
Phone (760) 346-3932 Fax (760) 346-8584
I hereby certify that I have read and understand the provision set forth in this authorization and agree to its terms.
August 14, 2022
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Patient Signature
Agree & Sign