MEDICAL AND SURGICAL WAIVERS
A. CONSENT TO TREAT AND MEDICAL AND SURGICAL WAIVER
This section states that you, the patient, consent to enter into a physician-patient relationship with Dr. Cober.
I consent to treatment, diagnostic, and or therapeutic treatment from Dr. Meshach Cober. By becoming a patient of Meshach Cober (“physician”) and Sanobo LLC (d/b/a Cober Health, and Cober Hernia, aka CH), I, the patient, agree to the following:
Physician does not purport to be a primary care, internal medicine, or family physician and does not claim to provide definitive care in these fields.
The patient should have a primary care physician and see appropriate medical specialists as needed.
The patient is utilizing the physician in an advisory capacity and is not to be a final and definitive medical decision-maker.
The patient will not sue the physician for a poor interaction, an adverse medical event, an adverse surgical event, medical malpractice, or medical negligence. I understand that the practice of medicine and surgery and patient outcomes are inherently unpredictable.
Before undergoing any surgery with the physician, the patient should obtain a second opinion from a board-certified general surgeon.
Before agreeing to any medical treatment of prescription therapy or any course of treatment, the patient should obtain a second opinion from a board-certified internal medicine physician, family physician, gynecologist, or subspecialist as is relevant to the particular diagnosis.
B. MEDICAL RECORDS RELEASE
This section states that you, the patient, allow us to communicate with other physicians, and insurance companies, and other medical personnel as it relates to your care and payment for services.
I hereby authorize CH to furnish my medical information to insurance carriers, referring physicians and/or any persons I designate. I give permission for any of my medical records, x‐rays, other hospital test(s) and/or any additional information contained in my medical records to be sent to CH via mail or fax or email. I understand that Dr. Cober and his staff may need to use and disclose information about my health or medical problems for the purpose of arranging, conducting, or referring treatments, for obtaining payments for services rendered to me and for the operations of the practice. I consent to the use of my information for the purposes of treatment, payment, and healthcare operations.
C. PAYMENT
This section states that you, the patient, agree to fulfill all financial obligations to us. We will make efforts to always disclose prices before they are due as much as possible given the complexities of the insurance reimbursement system.
I agree to pay all copays, deductibles, and other charges before the date of surgery. I authorize payments directly to Dr. Cober of all such insurance benefits payable to me. I authorize the doctor to release my medical information to such insurance companies as is necessary to receive payment for services rendered. I understand that all consultation fees are nonrefundable. I understand that self-pay patients are required to pay the physician before surgery. All self pay surgery fees must be paid by greater than 24 hours prior to the surgery time. Failure of payment will result in cancellation of surgery. I also assign CH all payments for medical services rendered to myself and/or my dependent(s). I understand that I am responsible for all co‐pays and/or balances not covered by my insurance carrier and that all payments are to be rendered at time of service. If my account becomes delinquent and is not resolved in a reasonable amount of time it may be turned over to an outside collection agency or legal action pursued.
CH may require payment prior to appointments or procedures. Furthermore, CH may incur fees or not refund payments if office cancellations are made by the patient without at least 24 hours’ notice. CH may incur fees or not refund payments if surgery cancellations are made by the patient without at least 72 hours’ notice.
D. STATEMENT OF NO MEDICAL MALPRACTICE COVERAGE
It is common for private practice surgeons in FL to elect not to carry malpractice insurance due to very high premiums in the state. We are legally required to inform you that Dr. Cober does not carry this insurance.
Under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against noninsured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida law.
E. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
We are legally required to inform you that you have rights to your health information and privacy.
CH will use your protected health information in the coordination of your care with insurance companies, hospitals, surgery centers, other doctors, lab and imaging centers and any other organizations as needed in the necessary operation of your medical care. Your permission is necessary before your health records are shared for any other reason. It is our duty at CH to protect your health information privacy. You have rights to protection of your privacy and you have the right to complain to the Department of Health and Human Services and CH if you believe your privacy rights have been violated. You may contact us via email or the phone number above to review your information, discuss anything, or complain. Your signature below affirms that you have received a copy to our privacy notice
(https://drive.google.com/file/d/1J7z6iUS704IplhKEwkbCep4iTfh66rwj/view?usp=sharing). Furthermore, it is for convenience sake that CH offers text and email communication for patients. Please note however that in general text and email is not encrypted and is more susceptible to data breach and thus private health-related information should be communicated via our secure messaging or document upload through your portal on Carepatron or Spruce or fax or our secure email on Spruce. Unless you otherwise state (“opt-out”) you agree to receive non-sensitive communication via email and text.
