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Month/Day/Complete Year

Consent for Treatment

The following are the conditions for services provided by Serene Care Clinics and it's Providers, and the entities and providers affiliated with them.

Medical / Psychiatric Consent

I consent to all treatment given under the general and special instructions of the NPs and Office Staff. Treatment may include, but is not limited to, diagnostic procedures, administration of injectable, oral and topical prescribed medication, psychotherapy services, the collection and utilization of cultures and laboratory specimens, and referral to specialty services for radiology, physician consultation, and other medical services, all of which may be considered medically necessary or advisable in the judgment of the Nurse practitioner (s) or their designees.

Assignment of Insurance Benefits and Third Party Claims

If the account is not paid at time of service, I hereby assign to SCC SCH the proceeds from the following: TRICARE medical benefits; PIP (personal injury protection); sick benefits; physician benefits; injury benefits; any health, accident or welfare benefits of any type or form relating to the patient, whether insured or self-funded; proceeds of any liability settlement or judgment being paid by or on behalf of a third party; and any other benefits due from the insurance policy. All amounts collected will be applied to the patient’s account. I understand that I am responsible for any charges not covered by insurance, Medicare, Medicaid, or other benefits. I further warrant and represent that any insurance or any plan that I assign is valid insurance and in effect, and that I have the right to make this assignment. In the event a claim for payment submitted by SCC SCH to my insurance carrier or plan administrator is denied, I hereby authorize SCC SCH to seek an administrative review of the disputed claim in accordance with the applicable provision(s) of my plan or policy. If my plan or policy is provided pursuant to the Federal Employees Health Benefits Act, 5 U.S.C. Section 8901 et seq., this review process will include, but is not limited to, a review by the Office of Personnel Management.

Financial Agreement

I understand that, if my insurance plan or policy requires a co-payment from me, I am required to pay that co-payment at the time service is rendered. I understand that, if I am self-funded, full payment is due at time of service. I understand that I am obligated to pay the patient account according the regular rates and terms of GHS UMG. I appoint SCC SCH as my true and lawful attorney to collect the claims, endorse the checks, and give full and final receipt for all amounts collected. In the event benefits exceed the actual charges for this account, the payment will be posted to the intended account and the refund processed accordingly. I understand that SCC SCH may obtain my credit report for review in collection of this debt. In the event that this account is placed with a collection agency or an attorney for collection, I will pay all collection fees and reasonable attorney’s fees.

Medicare Patients

Should I be eligible for Medicare coverage, I request that payment of authorized Medicare benefits be made to SCC SCH on my behalf. I certify that the information given by me is correct, in applying for payment under Title XVIII of the Social Security Act.

Disclosure/Use of Health Information

I authorize SCC SCH to provide any health information related to this patient to the insurance company or other payor, for purposes of payment for the health care provided. I also authorize SCC SCH to provide health information to other physicians and healthcare facilities for continuing care. I further agree that SCC SCH can use the health information for operations such as peer review and outcomes analysis. I acknowledge that I have received a copy of the SCC SCH Notice of Privacy Practices.

Patient Photographs

I understand that a facial photograph may be taken at the first visit and periodically thereafter for identification purposes only and that it will be part of my medical record and will be subject to all the protection that other personal health information receives.


10806 Reisterstown Rd, Ste 1F 
Owings Mills, MD 21117

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We operate by Appointments Only

Open Hours

Tuesday – Friday: 8:30am – 6pm
Monday & Saturday: 10am – 4pm

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