I understand that Patient, which may be defined as me, my child or a child for whom I have legal responsibility, needs medical care and treatment and I consent to such treatment at Remedy Urgent Mobile Medical. Treatment provided by medical providers, nurses, and medical assistants at Remedy Urgent Mobile Medical may include evaluation and management, vaccinations, laboratory, and other testing; routine medical, nursing and medical assistant care and procedures. I understand that photos or video of Patient may be taken in connection with such treatment and for operational, quality improvement, and education purposes. I understand that Remedy Urgent Mobile Medical is affiliated with a teaching institution and agree that resident physicians, fellows, and students may observe and participate in the Patient’s care and treatment under appropriate supervision.
I acknowledge that no guarantees or warranties have been made with respect to treatment or services to be provided by Remedy Urgent Mobile Medical. I understand that all supplies, medical devices and other goods provided to Patient are provided by Remedy Urgent Mobile Medical AS IS and Remedy Urgent Mobile Medical disclaims any expressed or implied warranties.
I have been provided with information regarding Patient Rights and Responsibilities. This information tells me how to register a complaint or grievance that I might have relating to Patient’s care at Remedy Urgent Mobile Medical.
Communicable Disease Testing
I agree that if a Remedy Urgent Mobile Medical employee or provider is exposed to Patient’s blood or other bodily fluid, pursuant to Washington law, Remedy Urgent Mobile Medical may test Patient to determine the presence of communicable diseases including Human Immunodeficiency Virus (HIV) and hepatitis. I understand that these test results will be kept confidential.
I acknowledge that Remedy Urgent Mobile Medical may, in its sole discretion, remove, retain, or dispose of any tissue or body parts removed from Patient, according to OSHA guidelines.
I understand that Remedy Urgent Mobile Medical can provide notifications to my cell phone. These texts are Do Not Reply texts for informational purposes only and are not intended as a form of two-way communication. I acknowledge that standard text messaging rates and fees will apply, text messaging utilizes a public telephone network and full security is not guaranteed, and any person with access to my phone will be able to see these messages unless I take steps to protect my phone with a password or PIN.
Protected Health Information
Notice of Privacy Practices
I have received the Remedy Urgent Mobile Medical Notice of Privacy Practices. Any questions or concerns may be directed to Remedy Urgent Mobile Medical Privacy Officer.
Use and Disclosure of information
I understand that the Patient’s medical records are confidential and cannot be disclosed without my written authorization except as authorized by law. Authorized disclosures are addressed in the Notice of Privacy Practices I have received. I understand that Patient’s medical information includes past, present and future information and may include genetic testing / counseling, communicable disease information including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), records related to mental health treatment / psychiatric care and alcohol / substance abuse diagnosis or treatment (collectively, Medical Information). I authorize the release of that Medical Information, as part of the Patient’s medical record. I understand that Remedy Urgent Mobile Medical must keep Patient’s medical records for a time period required by law and then may dispose of them as permitted or required by law.
Consent for Electronic Sharing and Health Information Exchange
I authorize Remedy Urgent Mobile Medical to use Patient’s Medical Information for Patient’s treatment and related services. Unless I object below, I authorize Remedy Urgent Mobile Medical to release and send Patient’s Medical Information to Patient’s non-health care providers electronically and/or through a Health Information Exchange, an organization that provides services to enable the electronic sharing of health-related information. Medical Information disclosed pursuant to this authorization may be used for treatment, payment, and operational purposes. The Medical Information disclosed may become part of my non-Remedy Urgent Mobile Medical health care providers’ medical records and may be re-disclosed by the recipient and no longer protected by state or federal privacy laws. I understand that I can change my mind and withdraw this authorization at any time, but Remedy Urgent Mobile Medical cannot take back information that has already been electronically shared. This consent is valid unless I have withdrawn it.
- I do not authorize Remedy Urgent Mobile Medical to send text messages to my cell phone number.
- I do not want Patient’s Medical Information shared electronically with non-Remedy Urgent Mobile Medical health care providers. I understand, however, that if electronic sharing is required by law, Remedy Urgent Mobile Medical must act in compliance with the law.
- I do not want Patient’s Medical Information shared with Health Information Exchanges. I understand, however, that if electronic sharing with a Health Information Exchange is required by law, Remedy Urgent Mobile Medical must act in compliance with the law. I further understand that certain Medical Information may be shared with a Health Information Exchange in a manner that does not identify Patient.
I agree to pay for the full billed charges associated with goods and services provided to Patient regardless of any applicable insurance or benefit payments and understand that all amounts are due upon request and are payable to Remedy Urgent Mobile Medical. Except as prohibited by law, I agree to pay for any charges not covered and covered charges not paid in full by any applicable insurance and/or benefit plan including charges payable as co-insurance, deductibles, and non-covered benefits due to policy and/ or plan limitations, exclusions, and/or failure to comply with insurance and/or plan requirements. I also agree and understand that if Patient’s account becomes delinquent and is referred to an attorney or agency for collection or suit, I will be responsible for paying all charges, reasonable attorney fees, costs, and collection expenses. I consent to credit bureau inquiries and to receiving auto-dialed, computer generated and pre-recorded message calls to my cellular telephone and to any telephone number provided during Patient’s registration process from Remedy Urgent Mobile Medical, Providers, and their affiliates and agents including, without limitation, any account management companies, independent contractors, or collection agents. An estimate of the anticipated charges is available upon request. I understand that estimates may vary significantly from the final charges because of a variety of factors such as the course of treatment, intensity of care, Provider practices, and the need to provide additional goods and services.
Medicare/Medicaid Patients Only
I understand that the goods and services that I or Patient request to be provided to Patient may not be covered under Medicare/Medicaid as being reasonable and medically necessary for Patient’s care. I understand that Medicare/Medicaid or their ensuring agent determine the medical necessity of the goods and services that are requested for Patient. If Medicaid determines that certain goods and services are not medically necessary for Patient’s care and I request such goods and services be provided despite Medicare/Medicaid’s denial, I understand I am solely responsible for payment for those goods and services. If Patient is a Medicare/Medicaid managed care Patient, these provisions may not apply. I certify that the information given by or on behalf of the Patient in applying for payment under Medicare/Medicaid is correct. I authorize the release of medical or other information about Patient to the Social Security Administration, intermediaries, or carriers as needed for related Medicare/Medicaid claims.
Notice to Patients – Third Party Payer (Health Plan Member) Information
I acknowledge that based on the information I have provided at this time about Patient’s insurance or other third-party coverage for Patient, Remedy Urgent Mobile Medical IS/ IS NOT a participating provider under Patient’s third-party payer coverage, insurance, or benefit plan.
Assignment of Benefits
I irrevocably assign and convey directly to Remedy Urgent Mobile Medical, and any provider that provides services to Patient at Remedy Urgent Mobile Medical (Providers), all benefits and all interest and rights, including any causes of action, ERISA (Employee Retirement Income Security Act) breach claim or other legal/administrative claim and the right to enforce payment, under any insurance policies, benefit plans, indemnity plans, prepaid health plans, third-party liability policies, or from another payer providing benefits on Patient’s behalf for goods and services provided to Patient by Remedy Urgent Mobile Medical and Providers. I also authorize direct payment to Remedy Urgent Mobile Medical for the goods and services Remedy Urgent Mobile Medical and Providers provide to Patient. I authorize Patient’s plan administrator, insurer, and/or attorney to release to Remedy Urgent Mobile Medical and Providers any and all Plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from Remedy Urgent Mobile Medical or Providers needed to claim medical benefits. Under this assignment, I convey to Remedy Urgent Mobile Medical and Providers all of my rights to claim (or place a lien on) benefits related to goods and services provided by Remedy Urgent Mobile Medical Providers to Patient, including rights to any settlement, insurance or applicable legal or administrative remedies, including damages arising from ERISA breach claims, and the right to appeal or pursue any denied or delayed claims. Remedy Urgent Mobile Medical has the right to (1) obtain all information regarding the claim; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims, a cause of action, or right against any liable party, insurance company, benefit plan, or plan administrator. Remedy Urgent Mobile Medical may bring suit against any such benefit plan, plan administrator or insurance company in my name with derivative standing. This assignment is not and shall not be construed as an obligation of Remedy Urgent Mobile Medical to pursue such interest and rights.
Conditions to Use our Website
Your permission to use the Website is conditioned upon your agreement that you:
- You are 18 years of age or older, or you are accompanied by a parent/guardian with a valid form of ID;
- Will not copy or distribute any part of the Website in any manner without our prior written consent;
- Will provide accurate information when creating an account or registering for our Website;
- Will not allow others to use the Website under your User ID and account;
- Are solely responsible for your User ID and the activity that occurs through your User ID;
- Will not use the Website for any commercial purposes other than the specific commercial activities contained on the Website and will not use it to obtain data or personal information about any other users or to solicit other users or advertisers;
- Are solely responsible for any content provided by you on the Website, including but not limited to any discussion posts, profile information, links and pictures including the ownership of any licenses or rights necessary to use the work of others and will not submit any copyrighted materials or work subject to other’s proprietary rights;
- Grant the Website and other users a non-exclusive license to read your materials and to use, reproduce, distribute, prepare derivative works of and/or display any materials provided by you (this is not applicable to personal information submitted to request services); and
- Agree we have the right to remove any and/or all of your content and terminate your account with or without prior notice.
To access certain parts of the Website, we may require you to create an account and/or profile. All such information provided by you shall be accurate and you agree to keep said information up to date. Anyone whose privilege to use the Website was previously terminated by us may not register for another profile or account, nor use another’s profile or account to use the site or create an account on your behalf.
Because sharing User IDs is prohibited we assume that access to the Website through your User ID is, in fact, you. You are solely responsible for any and all access to the Website by persons using your User ID. If you believe your User ID is being used without authorization, notify us immediately at firstname.lastname@example.org.
We reserve the right to authorize the publishing of various content provided by you (hereinafter “User Generated Content or UGC”). You agree not to post or use any UGC in any way that:
- Infringes the copyright, trademark, trade secret, or other intellectual property or proprietary rights of others;
- Violates the privacy, publicity, or other rights of third parties;
- Is unlawful, false, inaccurate, defamatory, discriminatory, libelous, pornographic, obscene, abusive, threatening, harassing, hateful, or encourages conduct that would be considered a criminal offense, give rise to civil liability, violate any law, or is otherwise inappropriate, as determined by us in our sole discretion; or
- Could damage our company, parent company, sister companies, affiliates, advertisers, or other parties.
We are not obligated in any way to remove any UGC that may violate one or more of these restrictions. We may, but are not obligated to, remove any UGC in violations of these terms, terminate user accounts or take other actions. We are not responsible for any harm to you caused by UGC.
By using the Website, You agree not to:
- Conduct or promote any illegal activities;
- Attempt to reverse engineer or interfere in any way with the functioning of the Website or otherwise attempt to derive the source code of the software (including the tools, methods, processes, and infrastructure);
- Attempt to gain access to secured portions of the Website;
- Use the Website to generate unsolicited email advertisements or spam;
- Use any automatic or manual process to search or harvest information from the Website;
- Interfere in any way with the proper functioning of the Website; or
- Impersonate another user.
Links to Other Sites
We may have links to third-party websites that are not owned, controlled or operated by us. We do not assume any responsibility for the content, privacy policies, or practices of any other websites or their owners. We are not endorsing or recommending any other websites, products or services by the simple inclusion of a link to another website.
No Liability for Acts of Advertisers
You waive and release us, our officers, directors, representatives, employees and agents and all of our parent companies, affiliates, related companies and their officers, directors, representatives, employees and agents from, any claims, liabilities, damages, or injury arising from or related to any act or omission of any of the advertisers and/or any goods and/or services provided in connection therewith.
Likewise, we make no representations, endorsements, warranties regarding the merchantability, suitability, reputation, professionalism or any other warranties of any kind whatsoever regarding any advertisement on the Website.
Promotions, Sweepstakes, and other Contests
We reserve the right to, on occasion, offer special promotions, contests and/or sweepstakes intended to provide you an incentive to use or promote the Website or engage with advertisers or others associated with the Website. The applicable rules will be posted on the Website in or near the description of each such promotion. We reserve the right to interpret the rules related to any such promotion, contest or sweepstakes in our sole discretion, and you hereby agree to our interpretation.
We reserve the right to alter or discontinue the Website or any of the services provided herein at any time without prior notice. We also reserve the right to terminate this Agreement at our election and for any reason, without prior notice. This Agreement will automatically terminate if, in our sole discretion, you violate any of the terms and conditions set forth below. A termination will result in the immediate cessation of access to the Website. The Disclaimers of Warranty and Limitation of Liability, Indemnity and all terms and conditions related to your Content shall survive the termination of this Agreement.
Disclaimers of Warranty and Limitations of Liability
We provide the Website and the related services “as is”, “where is”, and “as available.” We make no express and/or implied warranties or guarantees about the Website, the goods and services described thereon or the Advertisers. TO THE MAXIMUM EXTENT PERMITTED BY LAW, WE AND OUR OFFICERS, DIRECTORS, AGENTS, VENDORS, AND THE MERCHANTS WHO ADVERTISE WITH US DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES THAT THE WEBSITE AND SERVICES ARE MERCHANTABLE, OF SATISFACTORY QUALITY, ACCURATE, TIMELY OR FIT FOR A PARTICULAR PURPOSE OR NEED. WE IN NO WAY GUARANTEE THAT WE WILL MEET YOUR REQUIREMENTS, IS ERROR-FREE, ACCURATE, RELIABLE, WITHOUT INTERRUPTION OR AVAILABLE AT ALL TIMES. WE MAKE NO GUARANTEE THAT YOU WILL BE ABLE TO ACCESS OR USE THE WEBSITE AT TIMES OR LOCATIONS OF YOUR CHOOSING.
YOUR SOLE AND EXCLUSIVE REMEDY FOR ANY DISPUTE OR CLAIM WITH US IS TO CEASE USE OF THE WEBSITE. WE, OUR AFFILIATES, OFFICERS, DIRECTORS, AGENTS, VENDORS, AND MERCHANTS WHO ADVERTISE HERE, SHALL NOT BE LIABLE FOR ANY INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL OR EXEMPLARY DAMAGES ARISING FROM YOUR USE OF, INABILITY TO USE, OR RELIANCE UPON THE WEBSITE IN ANY WAY. THESE EXCLUSIONS APPLY TO ANY CLAIMS FOR LOST PROFITS, LOST DATA, LOSS OF GOODWILL, WORK STOPPAGE, COMPUTER FAILURE OR MALFUNCTION, DAMAGE TO ANY OTHER EQUIPMENT, OR ANY OTHER COMMERCIAL DAMAGES OR LOSSES, EVEN IF WE KNEW OR SHOULD HAVE KNOWN OF THE POSSIBILITY OF SUCH DAMAGES. IF ANY JURISDICTION DOES NOT ALLOW THE EXCLUSION OR THE LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, IN SUCH JURISDICTION, OUR LIABILITY, AND THE LIABILITY OF OUR AFFILIATES, OFFICERS, DIRECTORS, AGENTS, VENDORS, AND MERCHANTS WHO ADVERTISE HERE, SHALL BE LIMITED TO THE EXTENT PERMITTED BY LAW.
In connection with the foregoing release, you hereby waive your rights under laws or regulations which state: “A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which, if known by him must have materially affected his settlement with the debtor” or similar language.
You agree to defend, indemnify and hold harmless us, our officers, directors, representatives, employees and agents and all of our parent companies, affiliates, related companies and their officers, directors, representatives, employees and agents from and against any and all claims, damages, obligations, losses, liabilities, costs or debt, and expenses (including but not limited to reasonable attorney’s fees) arising from: (i) your violation of any term of these Terms of Service; (ii) your violation of any third party right, including without limitation any copyright, property, privacy right, or any and all intangible or intellectual property rights; or (iii) any claim that any of your UGC causes damage to a third party.
We, or people from whom we obtained a license, retain ownership of all intellectual property rights of any kind associated with the Website, including all applicable trademarks, copyrights and other proprietary rights such as trade secrets. Through the use of this Website pursuant to this Agreement, you have a limited right to use the Website, but in no way are we granting any license to you under any of those intellectual property rights. We reserve all rights that are not expressly granted to you in this Agreement. You may print limited numbers of one or more pages from the Website for your personal use.
We retain, to the maximum extent possible, all ownership, without limitation, of all the text, software, scripts, graphics, photos, sounds, interactive features and the trademarks, service marks and logos contained therein (“Marks”) unless they are marks used by Merchants who have provided them to us for use on this Website. The Marks are owned or licensed to us, subject to copyright and other intellectual property rights under the law of the United States of America, the law of the jurisdiction where you reside, and international conventions. All content on the Website provided by us is provided to you “AS IS” for your information and personal use only and may not be used, copied, reproduced, modified, distributed, transmitted, broadcast, displayed, sold, licensed, or otherwise exploited for any other purposes whatsoever without the prior written consent of the respective owners. We reserve all rights not expressly granted in and to the Website.
You retain any intellectual property rights in any copyrighted materials and trademarks that are contained in UGC that you post to the Website. You grant us an irrevocable, perpetual, non-exclusive, royalty-free, fully paid, worldwide license, with rights to sublicense through multiple levels of sublicensees, to reproduce, make derivative works of, translate, distribute, publicly perform and publicly display in any form or medium, whether now known or later developed, make, use, sell, import, offer for sale, otherwise commercially exploit and exercise any and all such rights, under any and all of your intellectual property rights related to the UGC in any manner we choose.
If you believe we have infringed on your copyrights, please submit a notification pursuant to the Digital Millennium Copyright Act (17 U.S.C. § 512(c)(3)) in writing to email@example.com or to the copyright agent on file with the U.S. Copyright Office with the Subject: “copyright notice.” Your notice needs to include: (1) A physical or electronic signature of a person authorized to act on behalf of the owner of an exclusive right that is allegedly infringed; (2) Identification of the copyrighted work claimed to have been infringed, or, if multiple copyrighted works at a single online site are covered by a single notification, a representative list of such works at that site; (3) Identification of the material that is claimed to be infringing or to be the subject of infringing activity and that is to be removed or access to which is to be disabled and information reasonably sufficient to permit the service provider to locate the material; (4) Information reasonably sufficient to permit the service provider to contact you, such as an address, telephone number, and, if available, an electronic mail; (5) A statement that you have a good faith belief that use of the material in the manner complained of is not authorized by the copyright owner, its agent, or the law; and (6) A statement that the information in the notification is accurate, and under penalty of perjury, that you are authorized to act on behalf of the owner of an exclusive right that is allegedly infringed.
Acknowledgment of Financial Responsibility & Consent
By scheduling an appointment, you understand that we require payment at the time services are rendered. You understand that we will charge you for appointments canceled after one of our assistants have been dispatched. Dispatch Fee is NON REFUNDABLE. You further understand that the services rendered by our providers may not be a benefit covered by your insurance company and you are responsible for payment of all services provided regardless of whether the services are a covered benefit. Upon request, we will provide you with a detailed invoice for the services we provide to you and you may submit such invoice to your insurance company if you chose.
You wish to receive medical services from Remedy Urgent Mobile Medical.com and consent to the provision of medical services during this visit and future visits, including minor procedures that may be necessary, for example, sutures. You understand that you may withdraw your consent at any time by making it known to the provider treating you.
Modifications to the Agreement
Choice of Law and Dispute Resolution
To the maximum extent authorized by law, the laws of the State of Washington govern the interpretation of this Agreement and any disputes arising in connection with it, regardless of conflict of laws principles. Any claim or dispute between you and us, our officers, directors, agents, parent companies and vendors that arises out of or relates to this Agreement or use of the Website shall be decided exclusively by a court of competent jurisdiction located in the Tri-Cities area.
The section headings used herein are for convenience only and shall be of no legal force or effect. If any provision of this Agreement is held invalid by a court of competent jurisdiction, such invalidity shall not affect the enforceability of any other provisions contained in this Agreement, and the remaining portions of this Agreement shall continue in full force and effect. There are no third-party beneficiaries of this Agreement. You may not assign this Agreement or your rights and obligations hereunder, in whole or in part, to any third party without our prior written consent, and any attempt by you to do so will be invalid. No one shall be deemed a third-party beneficiary to this Agreement.