Consent to Treat Form
This Consent to Treat Form (“the Agreement”) is made and entered into by and between you (“the Patient”) and Healthcare Intermediaries, LLC (“the Company”).
By ticking the box at the end of this form, you understand and agree:
Nature of Services: The Company does not provide healthcare services. The Company acts as a facilitator between healthcare providers and patients.
Payment of Services: The Company submits bills on behalf of healthcare providers. Payment for any and all services facilitated through the Company must be made directly to the Company.
Indemnification: You agree to indemnify and hold harmless the Company, its subsidiaries, affiliates, and their respective officers, directors, employees, and agents from any and all liability, claims, demands, damages, costs, and expenses, including reasonable attorney’s fees, arising out of or in connection with any medical malpractice, negligence, adverse reactions, or any other actions or inactions related to the healthcare services facilitated through the Company.
Consent to Treatment: You hereby consent to the healthcare providers facilitated through the Company to administer and perform all procedures and treatments as may be deemed necessary or beneficial to your health.
Acknowledgement and Agreement: By ticking the box, you acknowledge that you have read, understood, and agree to all terms and conditions of this Agreement. You further agree that this form serves as your digital signature and affirmation of consent.
The Patient understands that they should consult with a legal advisor prior to ticking the box if any part of this Agreement is not fully understood. By ticking the box, the Patient affirms their understanding and acceptance of the terms outlined herein.