Consent to Care and Treatment

Consent for Treatment

I voluntarily consent to medical, preventive, diagnostic, and therapeutic care provided by Prime

Wellness Community Health Center (PWCHC), including in-person and telehealth visits as deemed appropriate by my provider. I understand I may ask questions, refuse treatment, or revoke this consent at any time in writing.

Privacy & Use of Health Information

I acknowledge PWCHC follows HIPAA regulations and may use/disclose my information for treatment, payment, or healthcare operations. I have access to the Notice of Privacy Practices.

Assignment of Benefits

I authorize direct payment of insurance benefits to PWCHC and understand I am financially responsible for non-covered services.

Emergency

In case of emergency, I authorize necessary care and/or transfer to an appropriate facility.