Thank you for pre-registering
for a COVID-19 test.

Uptown Office,
12201 Euclid Avenue,
Cleveland, Ohio 44106

Please complete the information below prior to your scheduled test.

(if younger than 17, legal guardian needs to be present for test)

General Consent for Services

Circle Health Services provides healthcare services to individuals. After you have read each section of this form, and have had the opportunity to ask questions, please sign and date it to indicate your agreement and consent to receive services. If at any time you need help completing this form or do not understand any section of this form, please notify a staff member who is available to read this form and answer questions. Service will not be provided to anyone who changes or alters the terms or language of this consent form.

Authorization for Treatment
I agree to permit Circle Health Services authorized personnel to perform such services, diagnostic, and therapeutic procedures that my treating provider(s) deem necessary for care. I understand that services may include primary care, dental care, assessment services, psychiatric treatment, individual and group counseling, case management, substance use crisis intervention, substance use intensive outpatient services, and other medical care deemed necessary by my provider(s). I understand that HIV testing is included with an annual physical examination, and I can request that HIV testing not be done.

I agree to permit x-rays, laboratory tests, breathalyzer tests, photographs for treatment purposes, routine medical treatment (for example, medications, injections, drawing blood for tests), emergency procedures as necessary and other services performed at the request of the provider(s) involved in my care.

I understand that, except in an emergency, any further treatment or procedures will be performed only after I have been informed of the benefits, material risks and complications associated with such treatment or procedures and I have given my consent.
I further understand that physicians, nurses, and other healthcare personnel in training, as well as physician, nurse, and other healthcare personnel acting as volunteers, may assist, be present and participate in providing my care.

I understand that my medical records will be accessible to authorized personnel and that Circle Health Services will comply with certain safeguards established by federal, state, and local law as well as by Circle Health Services’ policies. Medical records are retained in accordance with applicable law and pursuant to Circle Health Services’ record retention policies.

I understand that I can call the Mobile Crisis Team for psychiatric crises after hours and the Circle Health Services after hours line when Circle Health Services is closed.

I understand that for after-hours emergency care, I will go to the nearest emergency room or call 911.

Outcome of Treatment
I understand that participating in services may not produce a satisfactory or successful outcome. I also realize that, by not participating in services, my problem or concern may become more serious. I acknowledge that no guarantees have been made to me with respect to the results of my care or treatment. I understand that, in some cases, Circle Health Services may work with me to develop alternative treatment programs. I recognize that referrals may be made for services that Circle Health Services does not provide. However, I understand that I am not obligated to accept such referrals.

Right to Terminate Service
I understand that I can determine, within reason, what services I need and/or want, and that I may terminate or withdraw from these services at any time. I understand that I have the right to decline services, including medication, except in an emergency. I understand that I have the right to decline, refuse or terminate a service, and that this will not prevent me from continuing to receive services that I request. I understand that no right extends so far as to supersede health and safety considerations, I understand that, if I terminate or withdraw from service, I may lose the benefit that continued treatment could provide. If I refuse treatment that is suggested to me, I will not hold Circle Health Services responsible for any consequences resulting from my decision to refuse treatment.

Client Rights and Responsibilities
I have received and read the Client Rights and Responsibilities. I agree to carry out my responsibilities found in the Client Rights and Responsibilities.

Notice of Privacy Practices
I have received and read the Circle Health Services’ Notice Regarding the Use and Disclosure of Protected Health Information (Notice of Privacy Practices).

Financial Responsibility and Assignment of Benefits
In consideration of the services received or to be received, I assign to Circle Health Services all benefits, and I direct insurers to pay such benefits directly to Circle Health Services. I understand that I am financially responsible for any service billed that is not covered by my insurance. I understand that I can meet with a benefits representative regarding my insurance benefits, and if I am uninsured that I can apply for benefits. I understand that I am responsible for co-payments at the time of service. The sliding fee scale has been reviewed with me. I will not be denied service because of an inability to pay for service.

Copies of Documents
I understand that I may receive a copy of this form, and copies of the Client Rights and Responsibilities and Notice of Privacy Practices, at any time.

Circle Health Services staff may contact you by telephone with information such as noncritical laboratory test results, minor medication adjustments, or instructions from your doctor. Circle Health Services staff can leave detailed medical information on your voicemail with your consent. By signing this “Consent to Leave Voicemails”, you consent to Circle Health staff leaving voice mail messages containing detailed medical information on the phone number(s) listed below. This information may include, but not be limited to, demographic information (partial or full name, date of birth, address, etc.), billing information, medical information (diagnosis, medications, test results, etc.).

I understand that Circle Health Services cannot require me to sign this consent form in order to receive treatment. I understand that I have the right to revoke this consent at any time by sending a written request to Circle Health Services. This “Consent to Leave Voicemail” is valid until such revocation is received by Circle Health. My decision to revoke this consent does not apply to any information disclosed in a voicemail prior to the date of my revocation of this consent. I understand that I am entitled to a copy of this completed consent form.

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