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Signing a Contract

Consent for Communication
& HIPAA Authorization

Community Concierge Care (C3 Cares)
Location: Washington, DC
Website: www.C3cares.com
Phone: 202-888-6440
Effective Date: January 1, 2025

HIPAA Authorization for Use and Disclosure of Protected Health Information (PHI)

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By signing this form, I authorize Community Concierge Care (C3 Cares) to use and disclose my protected health information (PHI) for purposes of treatment, payment, and healthcare operations in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I have been offered the complete, detailed “Notice of Privacy Practices”.

 

This includes, but is not limited to:

  • Sharing relevant information with specialists, pharmacies, and labs

  • Coordinating care with other healthcare providers

  • Submitting claims to insurance payers

I understand that I have the right to:

  • Request restrictions on certain uses and disclosures of my PHI

  • Revoke this authorization in writing at any time, except to the extent action has already been taken

Patient Acknowledgment and Signature

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I acknowledge that:​

  • I have read and understand this consent form

  • I understand the risks of using unencrypted communication methods

  • I may withdraw my consent at any time by notifying C3 Cares in writing

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Consent for Communications​​

I consent to receive communication about the following areas: 

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  • Appointment information

  • Care instructions

  • Health education and outreach

  • Billing communications

Via the following methods:​​

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Communication via SMS (Text Messaging):

 

I consent to receive customer care messages from C3 Cares. Message and data rates may apply, and messaging frequency may vary.

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SMS consent is not shared with third parties or affiliates for marketing purposes.

 

Reply STOP to opt out, and Reply HELP for support.

 

Visit https://www.c3cares.com to see our privacy policy and our Terms of Service.

 

Risks: I understand that SMS is not a secure communication method and that messages may be intercepted or viewed by others with access to my mobile device.

 

Communication via Telephone (Voice):

 

Risks:  I understand that voicemails may be left on my answering machine or voicemail unless I specifically request otherwise. All voicemails will be vague asking you to call “the clinic at 202-888-6440”.

 

Communication via Email:

 

Risks: I understand that standard email is not encrypted or secure and may be accessed by unintended recipients. I acknowledge these risks and still wish to communicate via email. 

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Email consent is not shared with third parties or affiliates for marketing purposes.

Terms of ServiceEffective Date: 01-01-2025

Last Updated: 05-01-2025

 

By using services provided by Community Concierge Care (“C3 Cares”), whether through our clinic, telehealth platform, or website, you agree to the following Terms of Service.

 

1. Services: C3 Cares provides primary care and mental health services via in-person and virtual visits. You must be located in Washington, DC or a state in which our providers are licensed to receive care.

 

2. Medical Disclaimer: Our website and communications are not a substitute for emergency services. If you are experiencing a medical emergency, call 911 or go to the nearest emergency room.

 

3. Patient Responsibilities

You agree to:

  • Provide accurate and complete health information

  • Keep appointments or provide timely cancellations

  • Use prescribed medications responsibly

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4. Electronic Communication: By using our services, you consent to receive messages via phone and/or SMS and/or email and/or patient portal. You acknowledge that some forms of communication may not be secure and accept the associated risks. You will be asked to sign a consent form detailing which of these methods you authorize or deny permission.

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5. Payment and Insurance

You are responsible for:

  • Confirming your insurance coverage

  • Paying copays, deductibles, and self-pay fees

  • Resolving billing issues in a timely manner

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6. Termination of Care

C3 Cares reserves the right to discontinue care if a patient:

  • Repeatedly misses appointments without notice

  • Displays abusive or inappropriate behavior

  • Fails to comply with treatment plans

 

7. Website Use: All website content is the property of C3 Cares and may not be copied or distributed without permission. Use of our site is at your own risk and provided “as-is.”

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8. Governing Law:  These terms are governed by the laws of the District of Columbia. Any disputes arising from your use of our services will be resolved under DC jurisdiction.

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