Authorization for Medical Treatment: I give permission to the physicians, psychologists, therapists, their assistants, and/or designees involved in my care at Eagle View Psychiatry (“Facility”) to administer any necessary or advisable treatments for my diagnosis and care. This includes, but is not limited to, routine diagnostic procedures, rehabilitation therapies, laboratory tests, and prescribed medications. I also authorize the release of copies of my medical records to other physicians and healthcare facilities as needed by my treating physician(s) or therapist(s). I understand that medicine is not an exact science, and no specific outcomes can be guaranteed for any examinations or treatments provided at this Facility. I acknowledge that my care is managed by my treating physician(s) and the Facility, and I agree to follow the instructions given by my physician(s) during my treatment.
Statement of Responsibility: I understand that I am financially responsible for any charges not covered by the above assignments. This includes any medical insurance deductibles, co-insurance, or out-of-pocket expenses, whether I am the patient, parent, guardian, conservator, or the insured party.
Notice of Privacy Practices: I have been given the opportunity to review Eagle View Psychiatry’s Notice of Privacy Practices concerning Protected Health Information. I am aware that the Facility may change this Notice at any time, and I can obtain the most current version at the Facility’s office during regular business hours.
Patient Rights & Responsibilities: I have had the chance to review the Patient Rights & Responsibilities at Eagle View Psychiatry. I understand that these may be updated at any time, and I can get a current copy at the Facility’s office during normal business hours.
By signing below, I confirm that I have read and understood the above information and am either the patient, the patient’s guardian, power of attorney, parent, or otherwise authorized to enter into this agreement and accept its terms.
