PATIENT RESPONSIBILITIES FORM
Doctors, area clinics, pharmacists, hospitals and many others are donating their services to help you get well and stay well. They are not being paid for the services provided to you. This is not a government program, nor an entitlement program. The donated care may end at any time, for any reason. HealthAccess does not include emergency room expenses or ambulance services. By signing this form you authorize HealthAccess to verify what you have reported during the application process. You may also receive some bills, for which you are responsible, should you need services not currently being donated for the HealthAccess program.
You agree that you:
- Will not schedule appointments with any doctor, clinic or hospital other than the ones to which you have been referred.
- Will follow your treatment plan, for example: get prescribed medicines and take as directed.
- Will promptly supply any information which may be requested by the program within the time frame requested.
- Will allow all information regarding your participation in this program to be shared with other individuals, organizations and agencies at the discretion of SCMS HealthAccess in accordance with state and federal laws.
- Will immediately contact your enrollment site or SCMS HealthAccess if your income changes or you become covered by Medicare, Medicaid, private insurance, other health insurance or medical benefits.
- Will apply for Medicaid, Healthwave or other assistance programs if and when you are eligible.
- Will authorize the State Department of Social and Rehabilitation Services to share information regarding your eligibility for Medicaid and other SRS programs with SCMS HealthAccess staff and with SCMS HealthAccess medical providers.
- Will contact SCMS HealthAccess immediately with any changes in address or phone number.
You agree to:
- Keep each doctor’s appointment. (if you miss 3 or more appointments in 12 months without
- letting the doctor’s office know at least 24 hours before your appointment, you will be disenrolled from the program.)
- If you are unable to keep an appointment, you are responsible for notifying the doctor’s office with whom you are scheduled, at least 24 hours in advance to cancel and reschedule the appointment.
- Present your SCMS HealthAccess Patient I.D. card each time you see a doctor.
- Call your enrollment site or SCMS HealthAccess doctor if you need to be seen anywhere else for care.
You understand that:
- There is a 12 month maximum coverage of $1000, and a maximum cost of $200 per prescription, unless funds are available and preauthorized by SCMS HealthAccess.
- Most types, but not all generic medications are available through this program. Your physician may be contacted and asked to use medications which are covered by the program.
- A pharmacy may stop participating at any time, for any reason.
- A co-pay per prescription will be required by your pharmacy.
- You are to present your medication card each time you have a prescription filled.
- HealthAccess will not discriminate based on race, religion, color, sex, disability, age, national origin or ancestry, or in any other manner as described in state and federal guidelines.
- HealthAccess does not provide medical care or services and does not make decisions regarding medical treatment plans. Those decisions remain between the providers and patients.
- All voluntary providers are independent contractors; they are not considered agents or employees of HealthAccess.
- HealthAccess is not responsible for bodily injury or negative outcomes potentially experienced within the provision of services by voluntary care providers. HealthAccess cannot guarantee the skill, care or training of voluntary providers