I consent to the treatment and any procedures that may be performed by my medical group, AC Wellness, and its affiliated health care providers, including but not limited to laboratory procedures, x-ray examinations, emergency treatment, medical treatment or procedures, anesthesia or other services provided to me. I also consent to my providers taking photographs of me for treatment and AC Wellness clinician education purposes only.
I acknowledge that if United Healthcare (UHC) is my insurer, it will share information about my health care with AC Wellness. AC Wellness will combine this information with my medical records to provide better medical care to me and to its patients. If I do not want UHC to share my health information with AC Wellness, I may opt out by contacting firstname.lastname@example.org. I understand that opting out will not affect my ability to receive care from AC Wellness. I acknowledge that even if I opt out my physician will still have access to my UHC information through the UHC portal.
I acknowledge that AC Wellness may arrange for me to connect with healthcare providers using telehealth technologies. I agree to the License Agreement for such use, and understand and agree that:
The AC Wellness provider will decide whether it is appropriate to treat my condition using the telehealth technology.
The AC Wellness provider may require an in-person examination prior to or after diagnosing or prescribing treatment.
The response time for electronic communications varies and I accept any risk associated with the response time, including a delay in obtaining medical care.
No warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.