1. Consent for Treatment
I voluntarily consent to receive medical care and services provided by Advanced Care Tech, LLC and its affiliated healthcare providers. This includes, but is not limited to:
Outpatient evaluation and treatment, Emergency care as needed, Medications and injections, Laboratory testing and imaging (including x-rays), Medical photography for diagnostic or treatment purposes
All care will be provided under the direction of licensed clinicians and authorized medical staff.

2. Financial Responsibility
I understand that payment is due at the time of service. I agree to be financially responsible for all services rendered by Advanced Care Tech, LLC and its providers.

Acceptable payment methods include cash, Visa, MasterCard, Discover, and American Express.
If I do not have health insurance, I agree to pay the full cost of my visit at the time of service.

If Advanced Care Tech, LLC participates with my insurance provider, I understand that I am responsible for any applicable co-pays, deductibles, co-insurance, and any charges not covered by my policy.

I acknowledge that:
My insurance contract is between me and my insurance company.
I must present valid insurance information at every visit.
If my insurance coverage cannot be verified in advance, I will pay in full at the time of service. A refund will be issued if insurance reimbursement is later received.
I remain responsible for any balances not paid by my insurance.
If another individual signs this agreement on my behalf (e.g., spouse or guarantor), that person agrees to be jointly and individually liable for payment. If my account is referred to collections or legal counsel, I agree to pay reasonable attorney’s fees, court costs, and collection expenses. Unpaid balances referred to an outside agency will accrue interest at the prevailing legal rate from the date of referral.

3. Insurance Authorization and Coordination
I authorize payment of medical benefits from Medicare, Medicaid, private insurance, or any applicable health plan directly to Advanced Care Tech, LLC for services provided.

I also authorize Advanced Care Tech, LLC to:
Disclose relevant portions of my medical records to insurers, government agencies, worker’s compensation programs, or other entities involved in claims processing or healthcare coordination.

Act on my behalf to obtain prior authorizations or pre-certifications when required.

Receive information from my insurer necessary to process claims.




4. Release of Medical Information
I authorize Advanced Care Tech, LLC to share my medical information with other licensed healthcare professionals or facilities involved in my care. This includes providing my records to my Primary Care Physician (PCP) to ensure continuity of care.

5. Notice of Privacy Practices
By signing this agreement, I acknowledge that I have received or been offered a copy of Advanced Care Tech, LLC’s Notice of Privacy Practices, which explains how my protected health information may be used or disclosed. I understand that this notice may be updated and that I may request a current version at any time.

6. In-Office Medication Dispensing
For my convenience, Advanced Care Tech, LLC may offer certain prescription medications in-office.
I understand:
These are optional and not billed to my insurance or pharmacy benefit plan.
Any medication dispensed is a separate charge in addition to my visit.
I may request a written prescription at no additional cost to use an outside pharmacy of my choice.

7. Personal Valuables
Advanced Care Tech, LLC is not responsible for loss or damage to personal items including, but not limited to, money, jewelry, electronics, documents, eyewear, or other valuables brought into the facility.

Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information. Covered entities as that term is defined by HIPAA and Texas Health & Safety Code § 181.001 must obtain a signed authorization from the individual or the individual’s legally authorized representative to electronically disclose that individual’s protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law. Covered entities may use this form or any other form that complies with HIPAA, the Texas Medical Privacy Act, and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.