Patient Rights

As a patient, you have the right to:

1. Respect and Dignity

Receive considerate, respectful, and compassionate care regardless of race, color, national origin, religion, gender, sexual orientation, disability, or ability to pay.

2. Privacy and Confidentiality

Expect that your personal health information and records will be kept confidential, in accordance with federal and state privacy laws (HIPAA).

3. Information and Communication

Be informed about your diagnosis, treatment options, and prognosis in terms you can understand.

Request and receive copies of your medical records.

4. Informed Consent

Receive an explanation of any proposed procedure or treatment, including risks, benefits, and alternatives, before giving consent.

5. Participation in Care

Participate actively in decisions regarding your care and treatment plan.

Refuse treatment to the extent permitted by law and be informed of the possible consequences.

6. Access to Care

Receive appropriate evaluation, treatment, and referral within the capabilities of the provider or facility.

7. Complaint Resolution

Express concerns or complaints about your care and receive a fair and timely review without fear of retaliation.

8. Telehealth Rights (if applicable)

Receive care via telehealth technology in a private and secure manner.

Refuse telehealth services and request in-person care when available.

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Patient Responsibilities

As a patient, you are responsible for:

1. Providing Accurate Information

Giving complete and accurate information about your health, including past illnesses, medications, allergies, and other relevant details.

2. Following the Treatment Plan

Following the agreed-upon treatment plan and notifying your provider if you have questions or difficulties following it.

3. Respect and Consideration

Treating healthcare providers, staff, and other patients with respect and courtesy.

4. Appointments and Attendance

Arriving on time for appointments or giving appropriate notice if you need to cancel or reschedule.

5. Financial Responsibility

Providing accurate insurance information and fulfilling financial obligations for your care promptly.

6. Use of Telehealth Technology (if applicable)

Ensuring you have a private, safe, and appropriate environment for telehealth sessions.

Not recording or distributing telehealth sessions without prior consent.



Release of Medical Information – Patient Summary

What this means
By signing the Release of Information form, you are allowing our clinic to share your medical information when needed and as you request.

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What information may be shared
This may include:
Notes from your urgent care or telehealth visit
Diagnoses and treatment plans
Medications or prescriptions
Lab or test results
Billing or insurance information
Only the information needed for the approved purpose will be shared.

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Why information may be shared
Your information may be released for reasons such as:
Continuing or coordinating your medical care
Referrals to another provider or specialist
Insurance, billing, or payment purposes
At your request (for personal use or another provider)

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Who may receive the information
Information may be shared with:
Other healthcare providers involved in your care
Insurance companies or billing partners
Individuals or organizations you specifically authorize

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Telehealth visits

Because your visit was provided by telehealth, information from your virtual visit (such as video, audio, images, or electronic messages) may be part of your medical record and shared as authorized.
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Your rights

Signing this form is voluntary and not required to receive care
You may cancel (revoke) this authorization in writing at any time
Once information is shared, it may no longer be protected by HIPAA if re-shared by the recipient
This authorization expires on the date listed on the form or within one year if no date is specified
If you have questions about how your information is used or shared, please contact our clinic.

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Acknowledgment

I have read and understand my rights and responsibilities as a patient.

I acknowledge that I may request a copy of this form for my records.

 

USave Health

Practice/Company Name: USave Health

Primary Business Address: 2630 W Broward Blvd Suite 203-1842, Fort Lauderdale, FL 33312-1314

Phone: 954-870-4790

Email: policy@usavehealth.com

Website: usavehealth.com

 

Effective Date: [10/1/2025]

Last Updated: [10/1/2025]