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Medical Disclaimer

The information on this website is provided for general educational purposes only and should not be considered medical advice. It is not intended to diagnose, treat, cure, or prevent any condition. Do not rely on website content for medical decisions. Always contact our office directly for medical concerns or call 911 for emergencies. Use of this website does not establish a patient‑provider relationship.

Consent to Treat (required for all patients)

Consent to Treat
I voluntarily consent to receive medical care, evaluation, and treatment from the providers at ExcelCare. This may include physical examinations, diagnostic tests, laboratory services, and routine medical procedures.
I understand that I may ask questions at any time and that I may refuse any treatment to the extent permitted by law.
I acknowledge that no guarantees have been made regarding the results of my care.

HIPAA Acknowledgment (legally required)

 

HIPAA Notice of Privacy Practices Acknowledgment
I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices, which explains how my medical information may be used and disclosed.
I understand that I may request additional copies at any time and that I may ask questions about my rights under HIPAA.

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Financial Responsibility Agreement

Financial Responsibility Agreement
I understand that I am responsible for providing accurate insurance information at each visit.
I agree to pay all copays, deductibles, coinsurance, and any non‑covered services at the time of my appointment.
I understand that if my insurance denies a claim, I am responsible for the full balance.
I agree to notify the office of any insurance changes and understand that unpaid balances may affect future scheduling.

Telehealth Consent

Telehealth Consent
I understand that telehealth involves the use of electronic communication to receive medical care when an in‑person visit is not possible or necessary.
I acknowledge the following:

  • Telehealth has potential risks, including technical failures or limited privacy.

  • I am responsible for ensuring a private, secure environment during my visit.

  • Telehealth may not be appropriate for all conditions, and my provider may require an in‑person visit.

By signing, I consent to receive care via telehealth.

Patient Portal Terms of Use

Patient Portal Terms of Use
By using the patient portal, I agree to:

  • Keep my login information confidential

  • Use the portal only for non‑urgent communication

  • Understand that portal messages are not monitored 24/7

  • Avoid using the portal for emergencies or time‑sensitive issues

I understand that misuse of the portal may result in restricted access.

Authorization to Release Medical Records

Authorization to Release Medical Records
I authorize ExcelCare to release or obtain my medical records to/from: Excelcare
Address: 6 Blackstone Valley Pl Lincoln RI 02865
Purpose of Release: Treatment, continuity of care, personal use, insurance, or other (specify).
I understand that this authorization is voluntary and may be revoked in writing at any time, except where action has already been taken.

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