Consent to treat, financial policy, and communication preferences

Consent to treatment*

I voluntarily consent to medical and behavioral health evaluation and treatment provided by K. Johns Medical and its clinicians. I understand that the practice of medicine is not an exact science, that no guarantee has been made about the results of evaluation or treatment, and that I may withdraw my consent at any time. I understand that a screening or questionnaire completed on this website is not a diagnosis and does not create a clinician-patient relationship on its own.

Guardian authorization for minors

If the patient is under 18, I confirm that I am the parent or legal guardian with authority to consent to care for this child, and that I will notify the practice promptly of any change in custody or guardianship.

Financial responsibility*

I understand that I am financially responsible for all charges for services provided, including copays, coinsurance, deductibles, and any amounts not covered by my insurance. I authorize the practice to bill my insurance on my behalf and to release information necessary for that claim. I agree to provide current insurance information and to notify the practice of any changes. Balances are due at the time of service unless other arrangements have been made in advance.

Appointment and cancellation policy*

I understand that appointments must be cancelled or rescheduled at least 24 hours in advance, and that late cancellations and missed appointments may be subject to a fee that insurance does not cover. I understand that repeated missed appointments may affect my ability to continue scheduling with the practice.

Email and text acknowledgment

I understand that ordinary email and text messaging are not secure and may be intercepted. If I choose to receive appointment reminders by text or email, I accept that risk for that limited purpose and understand that clinical information will not be sent this way.

Authorization to share with named people

I authorize the practice to discuss my care with the people I named above. I understand I may revoke this authorization in writing at any time, and that revocation does not apply to disclosures already made.

Telehealth consent

I consent to receive care by live video or telephone when my clinician determines it is appropriate. I understand that telehealth has limitations, including the inability to perform a physical examination, that technology can fail, that I must be physically located in a state where my clinician is licensed at the time of the visit, and that my clinician may require an in-person visit instead.

Notice of Privacy Practices*

I acknowledge that I have been given the opportunity to review the Notice of Privacy Practices published on this website, which describes how my health information may be used and disclosed and my rights regarding that information.