CONSENT TO EXAMINATION, TESTING, AND TREATMENT

I, the undersigned patient (or authorized representative), hereby voluntarily consent to and authorize Red Canyon Medical Clinic, its physicians, nurse practitioners, physician assistants, nurses, medical assistants, and other authorized healthcare personnel (collectively, "Providers") to perform such medical examinations, diagnostic procedures, laboratory tests, imaging studies, and medical treatments as may be deemed necessary or advisable in the professional judgment of the attending Provider.

I understand and acknowledge that: (a) the practice of medicine is not an exact science; (b) no guarantees or assurances have been made to me regarding the results of any examination, test, or treatment; (c) I have the right to ask questions about any proposed examination, test, or treatment and to receive explanations in terms I can understand; (d) I have the right to refuse any examination, test, or treatment at any time, and such refusal shall not affect my right to future care; (e) I may revoke this consent at any time, except to the extent that action has already been taken in reliance thereon.

In the event of an emergency where I am unable to provide consent, I authorize the Providers to render such emergency treatment as they deem necessary in their professional judgment.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

This Notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

Red Canyon Medical Clinic is required by law to maintain the privacy of your Protected Health Information (PHI), provide you with notice of our legal duties and privacy practices with respect to PHI, notify you following a breach of unsecured PHI, and abide by the terms of this Notice currently in effect.

Uses and Disclosures: We may use and disclose your PHI for purposes of: (1) Treatment - to provide, coordinate, or manage your healthcare; (2) Payment - to obtain payment for healthcare services provided to you; (3) Healthcare Operations - for quality assessment, training, licensing, accreditation, and business planning activities.

Your Rights: You have the right to: inspect and copy your PHI; request amendments to your PHI; request restrictions on certain uses and disclosures; receive confidential communications; receive an accounting of disclosures; obtain a paper copy of this Notice.

Our Responsibilities: We are required to maintain the privacy and security of your PHI, provide this Notice about our privacy practices, and follow the terms of the Notice currently in effect. We will not use or disclose your PHI without your written authorization, except as described in this Notice or as permitted by law.

FINANCIAL RESPONSIBILITY AGREEMENT AND ASSIGNMENT OF BENEFITS

I understand and agree that I am financially responsible for all charges incurred for medical services rendered by Red Canyon Medical Clinic, regardless of insurance coverage. This includes, but is not limited to: copayments, coinsurance, deductibles, non-covered services, and any balance remaining after insurance payment.

Payment Terms: Copayments and known patient responsibility amounts are due at the time of service. Balances remaining after insurance processing are due within thirty (30) days of statement date. We accept cash, check, and major credit cards.

Insurance Filing: As a courtesy, we will file claims with your insurance carrier. However, your insurance policy is a contract between you and your insurer; we are not party to that contract. You are responsible for understanding your benefits and ensuring timely premium payments.

Assignment of Benefits: I hereby authorize and direct my insurance carrier(s) to pay directly to Red Canyon Medical Clinic any and all benefits due for services rendered. I authorize Red Canyon Medical Clinic to release any medical information necessary to process insurance claims.

Collection: Accounts outstanding beyond ninety (90) days may be subject to collection action. If collection action becomes necessary, I agree to pay all costs of collection, including reasonable attorney's fees, court costs, and collection agency fees to the extent permitted by law.

Medicare/Medicaid Patients: I certify that the information given by me in applying for payment under Title XVIII and/or Title XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits payable for related services.

APPOINTMENT POLICY AND MISSED APPOINTMENT FEE AGREEMENT

Arrival: Please arrive at least fifteen (15) minutes prior to your scheduled appointment time to complete any necessary paperwork. Patients arriving more than fifteen (15) minutes late may need to be rescheduled.

Cancellation: If you must cancel or reschedule an appointment, please notify us at least twenty-four (24) hours in advance. This allows us to offer the appointment time to another patient in need of care.

No-Show Fee: A "no-show" is defined as a patient who fails to appear for a scheduled appointment without providing at least twenty-four (24) hours advance notice. A fee of fifty dollars ($50.00) may be assessed for each no-show occurrence. This fee is not covered by insurance and is the patient's responsibility.

Repeated No-Shows: Patients with three (3) or more no-show occurrences within a twelve (12) month period may be subject to dismissal from the practice. Prior to dismissal, reasonable efforts will be made to contact the patient regarding the attendance issue.

Emergencies: We understand that true emergencies occur. Please contact us as soon as possible if an emergency prevents you from keeping your appointment, and fees may be waived at our discretion.

CONTROLLED SUBSTANCE PRESCRIBING POLICY

Red Canyon Medical Clinic follows all federal and state laws and guidelines regarding the prescribing of controlled substances (including but not limited to opioids, benzodiazepines, and stimulants). The following policies apply:

1. Treatment Agreement: A signed Controlled Substance Agreement is required prior to initiation of any controlled substance therapy for chronic conditions.
2. Single Provider: Controlled substances for ongoing conditions will be prescribed by one designated provider only. Requests to other providers in the practice will be denied.
3. Office Visits Required: Controlled substances will only be prescribed during scheduled office visits. Telephone, portal, or emergency refill requests will not be honored except in documented extenuating circumstances at provider discretion.
4. Monitoring: Regular follow-up appointments (minimum every three months) are required. Random urine drug screens and pill counts may be required and must be completed when requested.
5. PDMP Verification: Prescription history will be verified through the state Prescription Drug Monitoring Program (PDMP) prior to each prescription.
6. No Early Refills: Prescriptions will not be refilled early. Lost, stolen, or destroyed medications will NOT be replaced regardless of circumstances. Police reports do not constitute an exception to this policy.
7. Violations: Violation of these policies, including but not limited to evidence of diversion, obtaining controlled substances from multiple providers, falsification of records, or positive drug screens inconsistent with prescribed medications, may result in tapering and discontinuation of controlled substances and/or discharge from the practice.

CONSENT FOR TELEHEALTH SERVICES AND HEALTHCARE TECHNOLOGY

Telehealth Services: I understand that telehealth involves the use of electronic communications, including video conferencing, to enable healthcare providers to deliver services remotely. I understand that: (a) telehealth has limitations compared to in-person visits; (b) the provider may determine that telehealth is not appropriate for my condition and require an in-person visit; (c) technical difficulties may occur; (d) telehealth services are billed similarly to in-person visits.

Electronic Health Records (EHR): I understand that Red Canyon Medical Clinic maintains electronic health records and uses certified EHR systems to document, store, and transmit my medical information in accordance with HIPAA regulations.

AI-Assisted Documentation: I understand and consent to the use of artificial intelligence (AI) and machine learning tools to assist with clinical documentation, including but not limited to: ambient listening technology for visit documentation, AI-assisted medical scribing, automated coding suggestions, and clinical decision support systems. I understand that: (a) all AI-generated documentation is reviewed and approved by my healthcare provider before becoming part of my medical record; (b) final clinical decisions are made by licensed healthcare providers, not AI systems; (c) I may request a copy of any AI-assisted documentation in my record.

Communications Technology: I consent to receive communications regarding my care via telephone, text message, email, patient portal, and postal mail, including appointment reminders, test results, billing information, and health maintenance reminders. I understand these communications may contain protected health information and I am responsible for maintaining the security of my devices and accounts.

AUTHORIZATION FOR COMMUNICATION

I authorize Red Canyon Medical Clinic and its representatives, agents, and business associates to contact me using any of the contact methods I have provided, including but not limited to: home telephone, cellular telephone (including calls and text messages), email address, patient portal, and postal mail address.

I understand that these communications may include: appointment reminders and confirmations; laboratory and test results; billing statements and payment reminders; prescription refill notifications; preventive care and health maintenance reminders; satisfaction surveys; and other healthcare-related communications.

I understand that: (a) standard message and data rates may apply for text messages; (b) email and text communications may not be encrypted and carry inherent privacy risks; (c) I may opt out of certain communications at any time by contacting the office; (d) opting out of appointment reminders does not relieve me of responsibility for scheduled appointments.