Emergency Contact
Informed Consent to Medical Service
I hereby authorize Urban Medical Center to treat me as necessary in their judgment.
The procedure(s) necessary to treat my condition has been explained to me by the staff and physicians of Urban Medical Center and I fully understand the nature of, and risks associated with, these procedure(s). I am aware that the practice of medical service is not exact and I acknowledge that no guarantees have been made to me as to results of this procedure(s), alternate methods and their consequences as well as the risks of refusing the described treatment(s) (if applicable) have been fully explained to me.
I understand that I have the right to ask questions about any proposed treatment or procedure, and that I may withdraw my consent at any time. I also understand that if I choose to refuse treatment, the risks associated with that refusal have been explained to me.
Signature of Patient / Guardian
Dr. Hyacinth Ucheagwu, MD
Patient Consent for Use and Disclosure of Health Information
- I hereby give my consent for Urban Medical Center to use and disclose protected health information about me to carry out treatment, payment, and health care operations (The Notice of Privacy provided by Urban Medical Center describes such uses and disclosures more completely).
- I have the right to review the Notice of Privacy prior to signing this consent. Urban Medical Center reserves the right to revise its notice of privacy practices anytime. A revised notice of privacy practices may be obtained by forwarding a writing request to Urban Medical Center, 95 Martin Luther King Drive, Jersey City, NJ 07305.
- With this consent, Urban Medical Center may call any home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out health care operations, such as appointment reminders, insurance items, and any calls pertaining to my clinical care, including laboratory test results, among others.
- With this consent, Urban Medical Center may mail or e-mail to my home or other alternative location any items that assist the practice in carrying out health care operations, such as appointment reminders, patient statements, and reminder cards, as long as they are marked personal and confidential.
- I have the right to request that Urban Medical Center restrict how it uses or discloses my personal health information to carry out health care operations. The practice is not required to agree to my request restrictions, but if it does, it is bound by this agreement.
- By signing this form, I am consenting to allow Urban Medical Center to use or disclose my personal health information to carry out health care operations.
- I may consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or revoke it, Urban Medical Center may decline to provide treatment to me.
Signature of Patient / Guardian
Advance Directive & Cultural Competency Assessment
Advance Directive
Advance directive is a federal and state Act. This allows the member to provide specific instruction regarding his or her medical care wishes if they ever became incapacitated. Insurance providers must ensure each member's medical record has documentation on how health services should be provided in an event when a member is unable to make a decision on their own behalf. Physicians who have a direct relationship with their patient are to provide a direct opportunity to discuss these types of decisions. All members who are 18 years of age and older must be asked and documented on their medical record for these type of services.
Cultural Competency
State of New Jersey mandates that every physician document any barrier to care (e.g. barriers can be cultural and/or religious custom, language, visual impairment, hearing deficit). Health ensures there members are provided with both clinical and non-clinical services are accessible and provided in a culturally competent manner. This means that all insurance providers must have a system in place that is responsive to the needs of the culturally diverse population that they service. Providers must provide services to members with a limited understanding of the English language, or a limited ability to read and write. Providers must also include ability to accommodate and provide health care needs to members with disabilities with physical and mental, ethical and cultural differences. Any factor affecting care that may impede the member's ability to understand medical discussion and/or impact the provider's ability to provide medical care; thus, requiring adjustments. The provider must have a method in place to assess these needs.
3. Do you have any impairment the office should know about?
Note: If patient does not have any barriers to care, document "NO Barriers to Care" in the medical record.
Signature of Patient / Guardian
