Patient Consent and Financial Policy

This service allows you, or, as applicable, a child for whom you are a parent or guardian, to receive medical consultations from the doctors, nurses and other healthcare providers of Montana Pediatrics, deemed in this policy as “Clinic”. By clicking “Agree” below or by using this service, you and the Patient are entering into a doctor/patient relationship with the Clinic as providers of medical services to the Patient and you agree as set forth below. As used in this policy, “you”, “your”, and “Patient” are deemed to include either yourself, if you are being treated, or any child for whom you are a parent or guardian if the child is receiving treatment.

Parent or Legal Guardian

I agree and confirm that I am the parent or legal guardian of the Patient. I understand and agree that the Clinic is relying on the truth of this statement. I agree that I am presently accessing this service for the purpose of seeking medical services, care or consultation for either myself or the Patient only and I am not using it for any other purpose or person.

Consent for Treatment

I give my permission for the Clinic to provide treatment to me or, as applicable, my child through telemedicine means. I understand that I have the right to refuse any procedure or treatment, and that I have the right to discuss all medical treatments and procedures with the clinician. I further understand that I have the right to seek additional treatment from other providers.

Use of Information and Records

I understand that notes created by the practitioner during the telemedicine consult will be shared with my or my child’s primary care provider for continuation of treatment. Likewise, I understand that my or my child’s primary care provider may, but is not required, to leave information about me or my child on the telemedicine system to assist with telemedicine treatment. While this information, to the extent available, is often helpful to the on call telemedicine provider, the telemedicine provider will make clinical judgments based on the totality of the information provided during the telemedicine consult, the provider’s own best practices and judgment, as well as any information that may be provided by other providers.

Personal and Medical Information

I agree to the entry of personal information regarding me and the Patient into the Clinic’s computer systems, including, without limitation, the software supporting this service. This information includes, but is not limited to, name, address, phone number, other contact information, credit card number, insurance information, medical records and medical history. The Clinic will endeavor to safeguard this information as required by HIPAA (the “Health Insurance Portability and Accountability Act”) and all other applicable laws. Please review the Clinic’s Notice of Privacy Practices to learn more about how your medical information may be used and disclosed and how you can get access to this information. You can access the Notice of Privacy Practices by clicking here.

Scope of Treatment

I agree that there is no guarantee that the Patient will be treated as a patient by the Clinic if the Patient’s medical condition cannot be properly treated by a Clinic healthcare provider. An appropriate referral will be made in such circumstances.

Payment for Service

The Clinic accepts most major private health plans, as well as Medicare and Medicaid. I understand I am responsible for paying the full amount for all services on the day of service, unless the Clinic has an agreement with my insurance carrier. I authorize the Clinic to release all information necessary to secure payment for services rendered to the Patient. I further understand that my share of the cost of the services, e.g., co-payments, co-insurance, and deductibles, will be collected following the service. Financial Assistance: The Clinic will not deny services to you if you do not have financial means to cover the cost of our services. Please ask us whether you qualify for Financial Assistance. Our Financial Assistance Policy can be accessed here.

Employer-Sponsored Programs

If you receive care as part of an employer-sponsored program, we will bill the appropriate entity under the arrangements between the Clinic and your employer. You are responsible for meeting all terms, conditions, and requirements for participation in such a program. You will be responsible for any Clinic charges that are not covered by the employer-sponsored program.

Insurance Claims

As a courtesy, the Clinic will file insurance claims with your insurance carrier. Your insurance company, in lieu of reimbursing you directly, will typically pay the Clinic for any benefits for services rendered. Your insurance carrier may pay less than the actual bill for services, so you may be responsible for payment of all services rendered. You are responsible for making available complete insurance information for accurate filing of claims. To meet this end, we will request your current insurance card at each visit. Reduction or rejection of your claim by your insurance company does not relieve the financial obligation you have incurred. It is your responsibility to know and understand your medical insurance coverage. Not all services are a covered benefit in all contracts. Additionally, some services we provide will be billed separately for the office visit and may require a separate co-pay or be applied to your co insurance/deductible. Please call your insurance company to verify your benefits. You will be responsible for all fees not paid by your insurance company except if you qualify for Financial Assistance.

For those who do not have health insurance, payment for services rendered is required at the time of service except if you qualify for Financial Assistance.