Right Place Health Consent for Treatment

Purpose of Care

Please read this form carefully before signing. If you have questions or need language assistance, please ask before signing.

I voluntarily request and authorize the healthcare providers at Right Place Health to provide medical evaluation, diagnosis, treatment, preventive care, laboratory testing, referrals, procedures within the provider's scope of practice, and other healthcare services that are considered medically appropriate.

I understand that my care may be provided by a licensed Nurse Practitioner or other authorized healthcare professionals working with Right Place Health.

Nature of Medical Care

I understand that:

  • The practice of medicine is not an exact science.

  • No guarantees or promises have been made regarding the outcome of my care or treatment.

  • My provider will explain recommended treatments, alternatives, and significant risks whenever appropriate.

  • I have the right to ask questions before accepting or declining any recommended treatment.

Patient Responsibilities

I agree to:

  • Provide complete and accurate information about my medical history, medications, allergies, and current symptoms.

  • Inform my provider of any changes in my health or medications.

  • Follow the treatment plan to the best of my ability.

  • Review messages sent through the FollowMyHealth portal.

  • Ask questions whenever I do not understand my diagnosis or treatment recommendations.

I understand that incomplete or inaccurate information may affect my medical care.

Diagnostic Testing and Referrals

My provider may recommend laboratory tests, imaging, vaccinations, referrals, or other services when medically appropriate 

I understand that I have the right to accept or decline these recommendations after discussing them with my provider.

Prescriptions

I understand that medications may be prescribed when medically appropriate.

  • I understand that:
    Medication decisions are based on my provider's medical judgment.
    Controlled substances may require additional evaluation, monitoring, or may not be prescribed depending on clinical circumstances and practice policies.
    Prescription refills may require follow-up appointments.

Emergencies

I understand that Right Place Health is not an emergency care facility. I understand that portal messages and voicemail are not monitored continuously. If I believe I  am experiencing a life-threatening emergency, I will call 911 immediately or go to the nearest emergency room.

AI-Assisted Documentation

To improve the quality and efficiency of documentation, Right Place Health may use secure, HIPAA-compliant technology, including artificial intelligence (AI), to assist in documenting medical visits.

If AI-assisted documentation is used:

  • My conversation with the provider may be transcribed for the purpose of creating a draft medical note.

  • AI technology assists only with documentation and does not make medical decisions or replace my healthcare provider's clinical judgment.

  • My healthcare provider will review, edit as needed, and approve my medical record before it becomes part of my permanent health record.

  • Any AI technology used by Right Place Health is intended to comply with applicable privacy and security requirements for protecting health information.

I understand that I may ask questions about the use of AI-assisted documentation during my visit.

Consent

I have read this Consent for Treatment, or it has been explained to me. I understand its contents, have had an opportunity to ask questions, and voluntarily consent to receive healthcare services from Right Place Health. 

Person Completing this Form (Required)

☐I am the patient

☐I am a helper assisting the patient complete this form

☐I am a Legal Representative of this patient (I have completed the Legal Representative form)

 

Signature of Patient or Responsible Party

____________________________________________