Online Enrollment

Food

To be provided to the individual patient before health care services are provided, except in emergency cases when notice may be provided as soon after the emergency as is practical, or to a parent or guardian when the patient lacks legal responsibility for his/her are under state law.

Notice to Patients

This is to notify you that under Federal law relating to the operation of free clinics, the Federal Tort Claims Act (FTCA), (See 28 U.S.C. §§ 1346(b), 2401(b), 2671-80) provides the exclusive remedy for damage from personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by any free clinic volunteer health care practitioner who the department of Health and Human Services has deemed to be an employee of the Public Health Service. This FTCA medical malpractice coverage applies to deemed free clinic volunteer healthcare practitioners who have provided a regular or authorized service under Title XIX of Social Security Act. The legal liability of the deemed individual is limited pursuant to section 224(o) off the Public Health Service Act, 42 U.S.C. 233(o).

(i.e.: Medicaid program) at a free clinic site or through offsite programs or events carried out by a free clinic (See 42 U.S.C. § 233(a), (o)).

The above federal law may cover certain free clinic healthcare professionals providing health care services to patients at this free clinic.

CONSENT FOR CHARITY CARE

Communication With Others

At CommonGood Medical we believe in team-based health care. That means that we, as health care providers have an active role, and you, as a patient have an active role.

CommonGood Medical is responsible for:

• Providing evidence-based primary care services.
• Providing considerate and respectful care.
• Explaining all procedures and test results at patient appointments. Providing reasonable answers to questions at appointments.
• Keeping all medical information private.

• Being on time for appointments. If you must cancel or reschedule, you must call us at (469) 712-4246 at least 24 hours prior to the appointment time. Leaving a voicemail will constitute contact.
• If you miss three appointments in one year without calling to cancel or reschedule, CommonGood Medical may discontinue care.
• As you are able, making a donation of any amount at each visit to help cover the costs associated with the care provided to the next patient.
• Obtaining any lab testing or imaging that is ordered by your physician prior to your next appointment.
Informing CommonGood Medical within 30 days of any change in your insurance status, income, or contact information. Failure to do so can result in delayed treatment.
• Timely providing updated patient enrollment documents (proof of residency and income) each year.
• Being an active partner in managing your health.