GMH Sphere

General Consent for Treatment: I, the undersigned, hereby consent to and authorize the performance of medical treatments, diagnostic procedures, and other medical services as may be deemed necessary or advisable by the physicians, practitioners, and staff of GMH in the course of my care. I understand that this consent includes, but is not limited to, routine diagnostic procedures, administration of medications, laboratory services, imaging studies, and other standard medical treatments.

Acknowledgment of No Guarantee: I acknowledge that no guarantees or assurances have been made to me concerning the results of any examination, treatment, or procedure. I understand that medicine is not an exact science and acknowledge that no guarantees have been made regarding the outcome of any treatments.

Authorization for Release of Information: I authorize GMH to release any medical information necessary to process insurance claims or for continuity of care. I authorize the release of medical information to my referring physician, primary care physician, and other healthcare providers directly involved in my care. I understand that this authorization complies with applicable federal and state privacy laws, including HIPAA.

Financial Responsibility: I understand that I am financially responsible for charges not covered by my insurance. I agree to pay all charges incurred in connection with my care that are not paid by my insurance carrier. I understand that co-payments, deductibles, and non-covered services are my responsibility and are due at the time of service unless other arrangements have been made.

Assignment of Benefits: I hereby assign to GMH all rights to benefits payable under any insurance policy, health plan, or other coverage I may have. I authorize payment of medical benefits directly to GMH. I understand that I am responsible for any balance not covered by my insurance.

Medicare / Medicaid Patients: I certify that the information given by me in applying for payment under Title XVIII and/or Title XIX of the Social Security Act is correct. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services.

Consent to Photography / Recording: I consent to the taking of photographs, video recordings, or other images for medical documentation purposes. I understand these may become part of my medical record and may be used for quality assurance, education, or treatment purposes, in compliance with HIPAA and applicable privacy regulations.

Notice Regarding Electronic Communications: GMH may communicate with you via email, text message, or patient portal regarding appointments, test results, billing, and other healthcare-related information. By providing your email address and/or mobile phone number, you acknowledge and consent to receiving such communications.

Risks of Electronic Communication: I understand that electronic communications, including email and text messages, are not always secure. There is a risk that electronic communications may be intercepted, misdirected, or accessed by unauthorized third parties. While GMH takes reasonable steps to protect the privacy and security of electronic communications, no method of electronic transmission is completely secure.

Patient Responsibilities: I understand that it is my responsibility to provide accurate and up-to-date email addresses and phone numbers. I agree to notify GMH immediately if my contact information changes. I understand that I should not use email or text messaging for urgent or emergency medical situations and should call 911 or proceed to the nearest emergency room in case of a medical emergency.

Types of Communications: I understand that GMH may send the following types of communications electronically:

• Appointment reminders and scheduling notifications
• Test results and lab reports (through secure patient portal)
• Billing statements and payment reminders
• General health and wellness information
• Prescription refill notifications
• Follow-up care instructions

Opt-Out: I understand that I may opt out of electronic communications at any time by notifying GMH in writing. Opting out will not affect the quality of care I receive.

HIPAA Compliance: GMH is committed to protecting the privacy of your health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable state laws. Electronic communications containing protected health information (PHI) will be handled in accordance with our Notice of Privacy Practices.

Notice of Privacy Practices Acknowledgment: I acknowledge that I have been offered a copy of GMH's Notice of Privacy Practices (NPP). The Notice of Privacy Practices describes the ways in which GMH may use and disclose my protected health information (PHI) for treatment, payment, healthcare operations, and other purposes as permitted or required by law.

Patient Rights: I understand that I have the following rights with respect to my health information:

• The right to request restrictions on certain uses and disclosures of my health information
• The right to receive confidential communications of health information
• The right to inspect and copy my health information
• The right to request amendments to my health information
• The right to receive an accounting of disclosures of my health information
• The right to obtain a paper copy of the Notice of Privacy Practices
• The right to be notified of a breach of my unsecured health information

Accuracy of Information: I certify that the information I have provided in this Registration and History Packet is true, accurate, and complete to the best of my knowledge. I understand that providing false or misleading information may affect my medical care and may have legal consequences.

Advance Directives: