NovaCare Quick Medical Center
Patient Consent, HIPAA Authorization & Financial Responsibility Agreement · Form NC-2026-A · Rev. 04.2026
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1. Consent for Treatment
I, the undersigned, voluntarily consent to receive medical and health care services from NovaCare Quick Medical Center, its physicians, nurse practitioners, physician assistants, nurses, technicians, and other authorized personnel. I understand that such services may include routine diagnostic procedures, laboratory tests, medical treatments, immunizations, and other care deemed medically necessary by my treating provider.
I acknowledge that no guarantees have been made to me regarding the outcome of any examination, diagnosis, or treatment. I understand that the practice of medicine is not an exact science and that results cannot be guaranteed.
2. HIPAA Notice of Privacy Practices
I acknowledge that I have been provided a copy of, or have been offered access to, the NovaCare Notice of Privacy Practices, which describes how my protected health information (PHI) may be used and disclosed in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and related regulations.
I understand that NovaCare may use and disclose my PHI for the purposes of: (a) providing treatment, (b) obtaining payment for services rendered, (c) conducting healthcare operations, and (d) any other use permitted or required by law.
3. Assignment of Insurance Benefits
I hereby authorize and direct my insurance carrier(s), including Medicare, Medicaid, and any other third-party payer, to remit payment directly to NovaCare Quick Medical Center for any services rendered. I understand that I am financially responsible for any portion of the charges not covered by my insurance, including deductibles, co-insurance, co-payments, and non-covered services.
4. Financial Responsibility
I understand that the co-payment collected today is an estimate based on the information provided by my insurance carrier and may be subject to adjustment after the claim is processed. Any balance owed will be billed directly to me, and any overpayment will be refunded in accordance with NovaCare's refund policy.
- Co-payments and deductibles are due at the time of service.
- Returned checks and failed card transactions are subject to a $25 processing fee.
- Accounts more than 90 days past due may be referred to a collection agency.
5. Communication Consent
I authorize NovaCare Quick Medical Center to contact me by telephone, voicemail, SMS text message, or email regarding appointment reminders, test results, billing matters, and other healthcare-related communications, using the contact information I have provided. Standard message and data rates may apply. I may revoke this consent in writing at any time.
6. Release of Medical Records
I authorize NovaCare and its authorized representatives to release, on my behalf, any medical records and information necessary to process claims for reimbursement, coordinate benefits, or communicate with other healthcare providers involved in my care.
7. Acknowledgment
By signing below, I certify that: (a) I have read or had read to me the contents of this form, (b) I have had the opportunity to ask questions and have had all of my questions answered to my satisfaction, (c) I understand and agree to the terms set forth herein, and (d) I am the patient, or I am duly authorized to consent on the patient's behalf.
This document is legally binding upon electronic signature. A copy will be provided via email or printed receipt.
