CONSENT TO TREATMENT FORM

Consent To Treat - English

Community Health Center of Lubbock, Inc. [CHCL]

CONSENT TO TREATMENT FOR CHCL CLINIC{S): I grant the physician(s), employees and such associates, assistants, and other health care providers as my physicians deem necessary attending me/my child the authority to treat and examine me/my child and order the examinations, tests, treatments and other services necessary for my care and treatment. I understand that this consent to treatment will be valid and remain in effect as long as I attend the Clinic(s) unless revoked by me in writing.

ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITY FOR CHCL CLINIC{S):I hereby authorize payment directly to the CHCL Clinic(s) for surgical or medical benefits, including major medical but not to exceed regular charges for these services. I understand that I am financially responsible to the CHCL Clinic(s) for charges incurred.

RELEASE FROM LIABILITY:CHCL Clinic{s) and its agents, representatives, and employees from any and all liability associated with the release of confidential patient information in accordance with this authorization. I understand CHCL Clinic(s) cannot be responsible for use or redisclosure of information by third parties.

MEDICARE / MEDICAID ASSIGNMENT FOR CHCL CLINIC{S):I request that payment of authorized Medicare/Medicaid benefits be made either to me or on my behalf to the CHCL Clinic(s) or other third party payor for any services furnished me by the CHCLClinic(s) health care provider. I authorize any holder of medical information about me released to the Health Care FinancingAdministration and its agents any information needed to determine these benefits or the benefits payable for related services.

Other persons who have permission to bring your children to the clinic.

Need a Doctor for a Check-Up?

Just make an appointment and we will take care of the rest.

The Community Health Center of Lubbock

Contact Information

CHCL Main Clinic
Address: 1610 5th Street, Lubbock, Texas 79401
Phone: 806-765-2611
Fax: 806-765-2637
E-mail: info@chcl.tachc.org
Notice of Deemed Status:
This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals. For more information, see http://www.bphc.hrsa.gov/ftca/.