Agreement As to Governing Law and Forum
The patient or the patient’s representative and health care provider, including employees and agents of the health care provider, rendering or providing medical care, health care, or safety or professional or administrative services directly related to health care to patient agree: (1) that all health care rendered shall be governed exclusively and only by Law and in no event shall the law of any other state apply to any health care rendered to patient; and (2) in the event of a dispute, any lawsuit, action, or cause of which in any way relates to health care provided to the patient shall only be brought in a Court in the county/district where all or substantially all of the health care was provided or rendered and in no event will any lawsuit, action, or cause of action ever be brought in any other state. The choice of law and forum selection provisions of this paragraph are mandatory and are not permissive.
Consent To Laboratory Testing & Use of Results
In consideration of services rendered, I transfer and assign any benefits of insurance to The Pain Center and its affiliates (known collectively hereafter as EPMed,PA) and authorize EPMed, PA to submit claims on my behalf directly to my health insurance provider/plan. I acknowledge that EPMed, PA may submit laboratory specimens to a licensed reference laboratory to perform testing. I authorize EPMed, PA to release to my insurance carrier, or any health plan of which I am a member, any medical information needed for claim processing. I understand that EPMed, PAmay be an out of network provider and my practitioner may hold an ownership interest in this laboratory, and as such, may receive a return of investment from this interest. I understand that I have the option of obtaining lab services from another facility and that upon my request will be provided a list of alternative laboratory facilities. I understand that if the insurance company pays me directly for services rendered by EPMed, PA, I am responsible to forward the payment to EPMed, PA. I agree that this Consent to Testing & Use of Results will cover all medical services rendered by EPMed, PA to me until such authorization is revoked in writing by me.
As required by Section § 102.006 of Texas Occupation Code
Texas law requires a physician to disclose to a patient those arrangements permitted under applicable Texas law whereby such physician accepts remuneration to secure or solicit a patient or patronage for a person licensed, certified or registered by a Texas health care regulatory agency. The purpose of this Disclosure is to notify you, the patient, that your attending physician(s) may receive remuneration for referring you to certain diagnostic testing laboratories, pharmacies, and/or other ancillary healthcare providers, for certain toxicology and pharmacogenetic testing services, compounding pharmacy products, diagnostic imaging services and other ancillary healthcare service including, but not limited to Gateway Surgical Center and EPMed, PA Laboratories. Accordingly, the undersigned hereby acknowledges that my attending physician(s) have disclosed to me, at the time of initial contact and at the time of referral (i) his or her affiliation, if any, with the diagnostic testing laboratory, pharmacy, ambulatory surgery center or other ancillary healthcare provider for whom, I, the patient, am being referred, and (ii) that he/she will receive, directly or indirectly, remuneration for the referral to such diagnostic testing laboratory, pharmacy, or other ancillary healthcare provider. I understand that I, the patient, have the right to choose the providers of my healthcare services and/or products and, as such, I have the option of receiving ancillary healthcare services from any ancillary healthcare provider and/or facility that I choose.