PATIENT SERVICE AGREEMENT AND CONSENT
Millie Medical Group, P.C. is honored to provide you with personalized support and care. Please read and sign the following agreement (“Agreement”), which lists services provided and the policies and procedures regarding scheduling, payment methods, confidentiality and compliance, and consent to email, text, and application messaging.
This Agreement governs the services provided by Millie Medical Group, P.C. and any affiliate or contracted medical care providers (“Provider”). Millie, Inc. (“Millie”) provides management and administrative services to the Provider.
- You agree to receive medical and/or mental health services, including related care management, medication management, and wellness services (the “Services”). You understand the risks, benefits, and alternatives of receiving these Services and have had the opportunity to ask questions. You may withdraw your consent to receive services by no longer seeking Services from Provider.
- Services may be provided via telehealth, which involves the use of synchronous (at the same time) and asynchronous (at different times) audio, video, or other electronic communications to interact with you, consult with your health care provider, and/or review your medical or mental health information for the purpose of diagnosis, therapy, follow-up, and/or education. During your telehealth consultation with providers from Provider, details of your medical history and personal health information may be discussed with other health professionals through the use of interactive video, audio, and telecommunications technology. The benefits of telehealth include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telehealth is that because of your specific medical needs, or due to technical problems, a face-to-face consultation still may be necessary after the telehealth appointment. Additionally, in rare circumstances, security protocols could fail, causing a breach of patient privacy. The alternative to telehealth consultation is a face-to-face visit with a physician or other healthcare provider.
Telehealth Services should not be used for a medical emergency; in a medical emergency or if you are feeling suicidal, you should dial 911.
2. Scheduling Services. All services can be scheduled by visiting millieclinic.com.
3. Cancellation Policy. You understand that your appointment, whether virtual or in person, must be canceled at least twenty-four (24) hours in advance or you will be responsible for full payment for the missed visit, unless your insurance prohibits us from billing you for missed visits.
4. Payment Methods. You understand and agree that payment for services shall be made prior to or at the time of service, except for the portion of the payment that may be covered by your insurance plan. Provider accepts payment in the form of credit card. If we accept your insurance and you will be using insurance to cover some or all of the cost of your appointment, you should contact Provider ahead of your appointment to ensure that your insurance is accepted. You should be prepared to pay any co-payments at the time of the appointment. You further understand and accept your financial responsibility for any portion of the bill not covered by your health insurer or health plan. If Provider is out-of-network for your insurance, you will be responsible for submitting the claim to your insurer for reimbursement.
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
5. Confidentiality and Compliance. Provider will take appropriate precautions to keep your health information confidential and to not disclose it without your consent. You are also protected under the provisions of the federal Health Insurance Portability and Accountability Act (“HIPAA”) and any other applicable federal and state laws related to protection of patient information. You have received a copy of our Notice of Privacy Practices (“NPP”), of which the most up-to-date version is posted on our website.
6. Mental Health Services Disclaimer. Mental health services may involve discussing sensitive aspects of your life in person or via telehealth; you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, or helplessness. If at any point you experience significant increased distress or have thoughts of harming yourself or others, you agree to notify your mental health provider so that an appropriate level of support can be provided. Your mental health provider may utilize a set of psychological symptom questionnaires in order to assist with determining a diagnosis and track your progress in counseling, and may discuss the nature of these assessments and your results when applicable.
7. Notice to Clients. The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.
Consent to E-mail, Text, and Application Messaging. By providing your e-mail and/or phone number to the Provider via the registration process and/or utilizing any Millie application, you agree to receive text messages, e-mails, and/or application messages from Millie, and its agents, on your cell phone or other devices. You understand that text messages, e-mails, and application messages sent by Millie may include appointment reminders or changes in previously scheduled appointments, or may provide advice or education. Because e-mails and application messages sent over the Internet or texts sent over the control channel without encryption are not secure, you understand the risks associated with text messaging, e-mail, and application messaging, including, without limitation, that text messages, e-mails, and/or application messages could be intercepted by unknown third parties, e-mail content can be changed without the knowledge of the sender or receiver, backup copies of e-mail may still exist even after the sender and receiver have deleted the messages, and e-mail can contain harmful viruses and other programs.
You understand that Millie has recommended that you delete all messages and e-mails as soon as possible after reviewing them to limit any unauthorized exposure.
If you communicate with Millie via e-mail, text message, and/or application message, you are consenting for Millie to respond to your e-mail or any messages sent utilizing the same method that you used.
8. Updates/Revisions. We may update this Agreement upon thirty (30) days’ notice to you. Notice will be provided via e-mail.
9. Disclaimers. TO THE MAXIMUM EXTENT NOT PROHIBITED BY LAW, EXCEPT IN CASE OF NEGLIGENCE OR WILLFUL MISCONDUCT, MILLIE AND ITS AFFILIATES, PROVIDERS, EMPLOYEES, OFFICERS, DIRECTORS OR AGENTS WILL NOT BE RESPONSIBLE FOR ANY LOSS OR DAMAGE, INCLUDING PERSONAL INJURY OR DEATH, RESULTING FROM ANYONE'S USE OF OR INABILITY TO USE THE MEDICAL SERVICES.
The Services are intended for use only within the United States and its territories. Millie makes no representation that the Services are appropriate, or are available for use outside the U.S. Those who choose to access and use our Services from outside the U.S. do so on their own initiative, at their own risk, and are responsible for compliance with applicable laws.
10. Limitation of Liability. TO THE MAXIMUM EXTENT NOT PROHIBITED BY LAW, IN NO EVENT WILL MILLIE AND ITS AFFILIATES, PROVIDERS, EMPLOYEES, OFFICERS, DIRECTORS OR AGENTS BE LIABLE FOR ANY CONSEQUENTIAL, EXEMPLARY, INCIDENTAL, SPECIAL OR PUNITIVE DAMAGES, INCLUDING WITHOUT LIMITATION THOSE RELATING TO LOST PROFITS OR THE COST OF SUBSTITUTE PRODUCTS OR SERVICES ARISING OUT OF OR IN CONNECTION WITH THE SERVICES OR FROM THE USE OF OR INABILITY TO USE THE SERVICES, WHETHER BASED ON CONTRACT, WARRANTY, PRODUCT LIABILITY, TORT OR OTHER LEGAL THEORY AND EVEN IF WE HAVE BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGES. SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE EXCLUSION MAY NOT APPLY TO YOU.