Additional details and expanded General Consent to Treat language can be found at:
CuranaHealth.com/privacy-policy/

1. I request services be provided to me by a Curana Provider, including but not limited to (as agreed to between me and my Curana Provider as part of my treatment plan):
   1. General medical care
   2. Behavioral health care
   3. Telehealth visits
   4. Chronic Care Management
   5. Advanced Primary Care Management
   6. Behavioral Health Integration
   7. Psychiatric Collaborative Care Model
   8. Transitional Care Management
   9. Use of Remote Medical Monitoring Devices
2. I assign all insurance benefits and/or Medicare/Medicaid benefits for the services provided above to Curana Providers and/or medical professionals providing services to me and authorize direct payment to Curana Providers.
3. I understand that the patient is financially responsible to the Curana Provider for all charges not covered by the above assignment. Charges may include co-payments, insurance deductibles, co-insurance or out-of-pocket expenses.
4. I consent to the use of medication(s) and/or therapies to be prescribed for their intended treatment purpose.
5. I consent to the use of ambient recording of medical visits for charting purposes.
6. I authorize Curana Health to share my medical records with other healthcare providers for treatment and coordination of care purposes.
7. If I am paying by insurance, I authorize Curana Health to release to my insurance company and/or to the Centers for Medicare and Medicaid Services and its agents any information needed to determine my benefits or the benefits payable to/for the services provided above, including but not exclusive of a clinical diagnosis, treatment plans and summaries, and/or copies of the entire record.
8. I authorize my Curana Provider to seek emergency medical care on my behalf if deemed necessary.
9. I understand that the services provided by my Curana Provider, including but not limited to those described in paragraph 1 above, are not emergency services, and that if I think I am experiencing a medical emergency, I will call 911 immediately or consult the medical staff on duty at my facility.
10. I understand that my Curana Provider may be required by law to report suspected abuse or neglect or to disclose my private information if they believe I may harm myself or others.
11. I understand that the Medical Group Notice of Privacy Practices describes how medical information about me may be used and disclosed. I acknowledge that the Medical Group Notice of Privacy Practices is available for me to access online at CuranaHealth.com/Privacy-Policy/ and is also available upon request.
12. I acknowledge that I have the right to refuse treatment without threat or termination of services except as otherwise provided by applicable law in the state of my residence. This consent for treatment may be withdrawn at any time.
13. Health Plan Statement: Unless I am a member of the following health plans, I understand that my Curana Provider is not providing treatment on behalf of health maintenance organization membership: Align Senior Care, AgeRight Advantage, Pruitt Health Premier, ProCare, NHC Advantage, KeyCare, Perennial, Lifeworks Advantage, and Lagniappe Advantage.

* If signed by a Patient Representative, please include signing authority paperwork along with this consent form. If more than one representative (i.e., separate Medical and Financial POA) please include authorizing paperwork for each role.