Patient Acknowledgement of Services
Consent for Treatment: I consent to Watermark Urgent Care’s administration and performance of general treatment, use of prescribed medications, performance of diagnostic procedures, tests and cultures, and performance of other laboratory tests that my physician or his designee determines medically necessary or advisable based on the judgment of my physician or their assigned designees. I give this consent in advance of any specific diagnosis or treatment. I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in force until revoked in writing; and a revocation of this consent will not affect the validity of my consent as to acts performed prior to the revocation. I understand that my consent on this form extends to other Watermark Health locations. A photocopy of this consent shall be as valid as the original. I understand that while my consent is voluntary, if I refuse to sign this consent, Watermark Urgent Care may refuse to treat me.
Minor/Disabled Patient: If I am signing this consent on behalf of a patient who is under age 18 or impaired in such a way as to make him or her unable to consent to or refuse treatment, I represent to Watermark Urgent Care that I have the legal authority to consent to treatment on such patient’s behalf and that I do in fact consent to treatment as described in the preceding paragraph. In such a case, references in this form to “I,” “me,” or “my” are intended as references to such patient where appropriate in the context.
Exposure Testing: I understand that in the case of an accidental exposure to blood or other bodily fluids, state law allows Watermark Urgent Care to perform an HIV test without obtaining the patient’s consent on a patient who may have exposed a healthcare worker to HIV.
Patient Responsibility for Follow-Up: I understand that it is my responsibility to follow any discharge and/or follow-up instructions Watermark Urgent Care may provide to me, including without limitation any recommended home-care and any follow-up examination and/or treatment by other healthcare providers. I accept full responsibility for the consequences of any failure by me to obtain recommended follow-up care and/or to comply with any other discharge instructions related to this Watermark Urgent Care visit.
Email/Text Messaging: If I have provided my email address/mobile number on this form, I understand that Watermark Urgent Care will keep that address confidential and will not rent or sell it. I understand that Watermark Urgent Care has requested my contact information in case Watermark Urgent Care needs to contact me. I consent to Watermark Urgent Care’s sending me, as a courtesy, 48-hour patient follow-up communications, satisfaction surveys, or urgent notices. I consent to Watermark Urgent Care’s sending unsecured emails regarding my Watermark Urgent Care visit to the email address I have provided on this form.
Consent to Telephone Calls: I consent to receive telephone calls and other communications on my cellular phone, other phone(s), and other communications devices, including autodialed calls and prerecorded messages. from Watermark Urgent Care and its successors, assigns, affiliates, agents, independent contractors, servicers, and collection agents. I understand these calls may regard my visit to Watermark Urgent Care or financial obligations related to my visit.
Volunteer Services: As a patient at Watermark Urgent Care, I acknowledge the following: As a patient at Watermark Urgent Care, I may receive healthcare services from a person who is a volunteer of Watermark Urgent Care who will not be paid and does not expect to be paid for the services. The clinic, employees, and volunteers providing healthcare services to me at Watermark Urgent Care are not liable for injury or death resulting from those services, as long as the injury or death does not result from an intentional act, willful negligence, conscious indifference, or a reckless disregard for safety. The only remedy for injury or death resulting from those services is under the Federal Tort Claims Act, 28 USC §§1346(b), 2401(b), and 2671-80. For more information, please visit: bphc.hrsa.gov/ftca
HIPAA Privacy Policies
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our Pledge and Legal Duty to Protect Health Information About You.
The privacy of your health information is important to us. We are required by federal and state laws to protect the privacy of your health information. We must give you notice of our legal duties and privacy practices concerning your health information, including:
We must protect information that we have created or received about your past, present, or future health condition, health care we provide to you, or payment for your health care.
We must notify you about how we protect your health information.
We must explain how, when, and why we use or disclose your health information.
We may only use or disclose your health information as we have described in this Notice.
We must abide by the terms of this Notice.
We are required to abide by the terms of this Notice. We reserve the right to change the terms of this Notice and to make new Notice provisions effective for all health information that we maintain. We will post a revised Notice in our offices and make copies available to you upon request.
USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
There are a number of purposes for which it may be necessary for us to use or disclose your health information. For some of these purposes, we are required to obtain your consent. In other specific instances, we may be required to obtain your individual authorization. And in a limited number of circumstances, we will be authorized by Law to disclose your health information without your consent or authorization. Following is a description of these uses and disclosures.
Uses and Disclosures of Your Health Information for Purposes of Treatment, Payment, and Health Care Operations.
Health Care Treatment. We may use or disclose health information about you to provide and manage your health care. This may include communicating with other health care providers regarding your treatment and coordinating and managing the delivery of health services with others. For example, we may disclose health information about you for a child and teen checkup, to your doctor or other health care services.
Appointment Reminders and Other Contacts. We may use your health information to contact you with reminders about your appointments, alternative treatments you may want to consider, or other of our services that may be of interest to you.
Payment. We may use or disclose your health information to bill and collect payment for the treatment and services provided to you. For example, a bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.
Health Care Operations. We may use or disclose health information about you to allow us to perform business functions. For example, we may use your health information to help us train new staff and conduct quality improvement activities. We may also disclose your information to consultants and other business associates who help us with these functions (for example computer support and transcription services).
Fundraising. As part of our health care operations, we may use or disclose your demographic information and dates of treatment to contact you to raise money for our organization.
Texas Patient Consent for Disclosures.
For some of the disclosures of health information described above, we are required by Texas Law to obtain a written consent from you, unless the disclosure is authorized by Law.
Uses and Disclosures of Your Health Information that Require Your Opportunity to Agree or Object. In the following instances we will provide you with the opportunity to agree or object to our use and disclosure of your health information:
Persons Involved in Your Care. We may, using our best judgement, disclose to a family member, or other relative, involvement in your care or payment related to your care.
Notification to Others. We may, in some instances, disclose health information about you to a family member, a personal representative, or another person responsible for your care, in order to notify such a person about your current location or general condition.
Uses and Disclosures Authorized by Law.
Under certain circumstances we are authorized by Law to use or disclose your health information without obtaining a consent or authorization from you. These may include when the use or disclosure is:
Required by Law. We will disclose your health information when such disclosure is required by federal, state, or local laws.
Necessary for public health activities. For example, when reporting to public health authorities the exposure to certain communicable diseases or risks of contracting or spreading a disease or condition.
Related to victims of abuse and neglect. For example, when reporting suspected victims of abuse or neglect.
For health oversight activities. For example, when disclosing health information to a state or federal health oversight agency so that they can appropriately monitor the health care system.
For judicial and administrative proceedings. For example, when responding to a request for health information contained in a court order.
For law enforcement purposes. For example, when complying with laws that require the reporting of certain types of wounds or injuries.
To a Coroner or Medical Examiner. To allow them to carry out their duties.
To avert a serious threat to health or safety. For example, when disclosing health information that will help prevent a serious threat to the health and safety of you or another person of the public.
Related to specialized government functions. For example, we may disclose health information about you if it relates to military and veteran’s activities or national security.
Related to Worker’s Compensation. For example, when reporting health information to entities that provide benefits for work-related injuries and illness.
Related to correctional institutions. And in other custody situations.
Uses and Disclosures of Your Health Information that Require Your Authorization.
Other uses and disclosures of your health information not covered in this Notice will be made only with your written authorization. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any uses or disclosures permitted by your authorization while it was in effect.
YOUR INDIVIDUAL RIGHTS
Right to Access and Copy Your Health Information. You have the right to access and receive a copy or a summary of your health information contained in clinical, billing, and other records that we maintain and use to make decisions about you. We ask that your request be made in writing. There might be limited situations in which we may deny your request. Under these situations, we will respond to you in writing, stating why we cannot grant your request and describing your rights to request a review of our denial.
Right to Request an Amendment of Your Health Information. You have the right to request amendments to the health information about you that we maintain and use to make decisions about you. We ask that your requests be made in writing and must explain, in as much detail as possible, your reason(s) for the amendment and, when appropriate, provide supporting documentation. Under limited circumstances we may deny your request. If we deny your request, we will respond to you in writing stating the reasons for the denial. You may file a statement of disagreement with us. You may also ask that any future disclosures of the health information under dispute include your requested amendment and our denial to your request.
Right to Request Restrictions on Uses and Disclosures of Your Health Information. You have the right to request that we restrict our use or disclosure of your health information. We ask that your request be made in writing. We are not required to agree to your request for a restriction, and we will notify you of our decision. However, if we do agree, we will comply with our agreement, unless there is an emergency or we are otherwise required to use or disclose the information, by Law or otherwise.
Right to Request Confidential Communications. Periodically, we will contact you by phone, email, or other means to the location identified in our records with appointment reminders, results of tests, or other health information about you. You have the right to request that we communicate with you in a specific way or as a specific location. For example, to be contacted at your work address or phone number. We will make efforts to accommodate reasonable requests.
Right to Request and Accounting Disclosure of Health Information. You have the right to request a list of certain disclosures we have made of your health information. We ask that your request be made in writing. You may ask for disclosures made up to six years before the date of your request.
Right to Receive a Copy of This Notice. You have the right to request and receive a paper copy of this Notice at any time. We will make this Notice available in electronic form and post it in our website.
If you have any questions about these rights or to exercise any of them, please contact our Privacy Officer listed below. If you are concerned that your privacy rights have been violated, you may file a complaint with our Privacy Office. You may also submit a written complaint to the U.S. Department of Health and Human Services. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Privacy Office Contact Information:
Address: 7616 LBJ Freeway, Suite 405, Dallas, TX 75251
This notice was published and becomes effective on or before March 21, 2022.
A copy of this form is available upon request.
(Early Prenatal Care)
Consent to Limited Ultrasound Services
I request an appointment for a limited ultrasound examination at Watermark Urgent Care for the purposes of confirming my pregnancy. A physician will review the ultrasound images and report to confirm the pregnancy diagnosis. I understand that a referral will be made to another medical provider for follow-up medical care.
I understand that a limited ultrasound examination is only for purposes of confirming my pregnancy, detecting fetal cardiac activity and determining estimated gestational age. I understand that it is not for the purposes of diagnosing or detecting any medical problem or condition for my baby or myself. I will not hold Watermark Urgent Care responsible for diagnosing or failing to diagnose any abnormalities or conditions relating to my pregnancy or my baby and hereby release Watermark Urgent Care from any and all liability in this regard.
I understand that ultrasound utilizes high frequency sound waves, and there are no confirmed effects in its more than thirty years of clinical use. I further understand that the possibility always exists that effects may be identified in the future.
I understand that no follow-up care will be provided at Watermark Urgent Care that is outside of the scope of Urgent Care and volunteer/staff provider on site and that its physicians and staff are not responsible for my follow-up prenatal care or for any emergency care that I may need. I understand that a referral list with the names of local doctors and prenatal health care providers is available for my use. I acknowledge that I have the duty and responsibility to use the referral list or some other source to secure my prenatal care.
I am not presently experiencing any immediate medical problem, and I understand that this exam is not a substitute for immediate medical care. Should any medical problems arise before my scheduled appointment(s) at Watermark Urgent Care, I acknowledge that it is my responsibility to seek emergency care.
I hereby give full consent to these medical services and I waive and release any and all claims of whatsoever kind and nature that I, my baby, my legal representatives or heirs and relatives might have, or hereafter have, against Watermark Urgent Care, its physicians, medical personnel, directors, officers, employees and volunteers.
I expressly agree that this waiver, release and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of this state, and that if any portion thereof is held invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect.
In order to effectively provide for my medical care, I understand that the staff and client advocates of Watermark Urgent Care will have access to my confidential records at Watermark Urgent Care. My records will not be released to any agency or individual without my permission except as required by law.
Permission is given to contact me following physician review of the ultrasound by Phone/Text.