AUTHORIZATION OF PAYMENT
I assign and authorize payment directly to MyHealth Urgent Care, P.C., a Management Company for this Urgent Care, for any and all services rendered. I understand that I am financially responsible for services that may not be covered under my health insurance policy. I understand that it is my responsibility to pay, at the time of discharge, or on an interim basis as arranged with MyHealth Urgent Care, P.C., in accordance with its Payment for Services Policy a copy of which I acknowledge that I have received, for all charges not covered by my insurance company, such as but not limited to deductibles and co-payments.
PRIVACY PRACTICES & RELEASE OF MEDICAL RECORDS
I acknowledge that I was offered and/or provided the MyHealth Urgent Care, P.C., Notice of Privacy Practices, and that I may obtain an additional copy of the Notice at any time. This Notice describes how MyHealth Urgent Care, P.C., uses and discloses medical information in accordance with the protections of the law.
I authorize MyHealth Urgent Care, P.C., to release pertinent information and/or copies of medical records of any information protected under the regulations in 42 Code of Federal Regulations, Part 2, if any, psychiatric/psychological/substance abuse/service records, if any, social work records, if any, including communications made to me by a social worker or psychiatrist/psychologist and any information about Human Immunodeficiency Syndrome (AIDS) to other institutions, physicians, third party payers, insurance companies or review agencies for use in connection with my care. I acknowledge that medical record information may be released to my employer if this is a work-related examination or injury for which a worker’s compensation claim has been filed.
NO CLIENT OR PATIENT RELATIONSHIP
No client or patient professional relationship is implicated or established and neither MyHealth Urgent Care nor any other person is, in connection with this site, engaged in rendering consulting or other professional health care services or advice. You should consult with your health care professionals who are familiar with your specific health care for advice before making any health care decision.
This site is provided by MyHealth Urgent Care on an “as is” basis. MyHealth Urgent Care makes no representations or warranties of any kind, express or implied, as to the operation of the site or the information, content or materials included on this site. MyHealth Urgent Care may provide links to other sites that are not maintained by MyHealth Urgent Care. MyHealth Urgent Care neither monitors nor endorses those sites nor does it make any representations or warranties with respect thereto.
By using our website, you consent to the collection and use of the information discussed above. Changes in this policy will be posted on this page so that you may always be aware of what information is being collected, how it is being used, and under what circumstances it is being disclosed.
ONLINE PAYMENT POLICY
All transactions processed via online bill pay are eligible for a refund if you would like to cancel a payment for any reason within 24 hours of your transaction. We will also refund any payment made in error or if the payment is not currently due and creates a credit balance on your account. Refunds for payments that are correct and made on an outstanding balance will not be refunded unless approved by the Billing Manager. To request a cancellation of an online payment and refund of your payment please call our Billing office at 248-289-1590 within 24 hours of your transaction. Online refunds will be processed as soon as they are approved via a credit to your credit card account. If you have questions regarding our refund policy, please call the Billing Manager at 248-289-1590 Ext 108.
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