TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be pregnant or breastfeeding during the treatment and for 6 months after treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date
TREATMENT AGREEMENT. Welcome to my practice! This document (The Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPPA), the federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment and health care operations. HIPPA requires that I provide you with Notice of PRIVACY Practices (the Notice) for the use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is included with this Agreement, explains HIPPA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I provided you with this information at the start of treatment. Although these documents are long and sometimes complex, it is important that you read them carefully. You will also receive a copy of this information to keep. We can discuss any questions you have about them after you have read them. Please make sure to let me know if there is any part that you do not understand. When you sign this document, it will also represent an agreement in writing at any time. That revocation will be binding on me unless I have taken action concerning it, re: if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy or if you have not satisfied any financial obligations you have incurred.
TREATMENT AGREEMENT. I agree to accept the following treatment contract for buprenorphine office-based opioid addiction treatment:
TREATMENT AGREEMENT. I agree to accept the following treatment agreement for extended-release injectable naltrexone (XR-NTX) office-based opioid use disorder treatment:
TREATMENT AGREEMENT. Welcome to my practice. This Informed Consent Agreement (“Agreement”) contains important information about my professional services and business policies. It is also intended to inform you of state and federal laws and your rights. We can discuss any questions you have before you sign this document or at any time in the future. You may revoke this agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it or if you have not satisfied any financial obligations you have incurred.
TREATMENT AGREEMENT. — I promise full cooperation with my treating physician whether by surgical or non-surgical means. I understand that if I do not follow my doctor’s instructions concerning my care and treatment, including any necessary medications, the outcome of my care and treatment could be put into jeopardy and less than optimal results may occur.
TREATMENT AGREEMENT. The Supplier is responsible for entering into a Treatment Agreement with the Hospital department treating the patient. The Treatment Agreement shall contain details with regards to the treatment (ordering procedures, contact information and so forth). The Treatment Agreement shall be archived by both the Supplier and the Customer. The Supplier is responsible for providing a copy to the Contract Manager.
TREATMENT AGREEMENT. ● I agree to keep all scheduled appointments for receiving TBs medication, to take all TB medication as prescribed, to comply with all diagnostic tests ordered by my doctor and to follow all other directions given to me by the County TB staff. ● If I fail to comply, I understand I may be quarantined in a state hospital with facilities for tuberculosis treatment or other appropriate facility as determined by the state and local health department by authority granted to the Health Officer by Annotated Code of Maryland, Health-General §§ 18-324,325 and the Code of Maryland Regulations 10.06.01.06
TREATMENT AGREEMENT. Treatment of your injury is our highest priority. We thank you for requesting us to participate in your care, and we ask that you follow through with us until your treatment is complete. • Please notify our office as early as possible if you think you will be unable to keep your appointment so that we may offer that time to another patient. Additionally, we would like to apologize for occasions when we are running behind. Because we are a trauma service, emergencies will arise. We are not under the illusion that our time is more important than yours and will make every effort to see you in a timely and efficient manner. • We strive to offer you the best evaluation and treatment of your injuries. Your payment is reimbursement for our professional services. By signing below, you agree to fulfill your financial commitment to our office. Additionally, you agree to pay for all costs related to collecting payment on your account, which can include attorney fees and other collection costs. • Orthopaedic Trauma Specialists will file claims with your insurance carrier. Our Billing Policy is as follows:
TREATMENT AGREEMENT. In the performance of treatments Medcare has an obligation of effort (inspanningsverbintenis) and not an obligation of result (resultaatsverbintenis). Medcare has an effort obligation to perform the treatment to the best of its knowledge and ability, but assumes no obligation to deliver a specific result or outcome. No guarantee is provided in respect of results or undisturbed course of treatment or outcome. Complications may arise, including infection, hemorrhaging, loss of tissue, numb skin, sensitivity, chronic pain, loss of smell or taste. Additional treatment may be necessary and may incur additional costs. Medcare has the right to have certain work performed by third parties. Medcare does not have to obtain permission from the client for this. Medcare shall not be liable for any acts and/or omissions of third parties.
