PATIENT AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I hereby authorize Advanced Podiatry to use and/or disclose to any party deemed reasonably necessary by Advanced Podiatry and its office staff, any and all of my protected health information. I understand that this authorization is valid as long as I am a patient of Advanced Podiatry. I understand that the purpose or use of the disclosure I am granting is to allow Advanced Podiatry’s office to use and disclose my protected health information as needed via the communication methods that you have provided (phone, email, address). You have the right to specify the preferred mode of communication. I expressly acknowledge that this authorization is voluntary. There are no other criteria or limitations that I make regarding this authorization. I understand that the office will not receive financial or in-kind compensation in exchange for using or disclosing the health information described above. I understand that this authorization may be revoked by the authorizer, in writing, at any time in accordance with the attached authorization revocation procedure. I also understand that the revocation of this authorization will not have any effect on disclosures occurring prior to the execution of any revocation. I understand that the information used or disclosed pursuant to this authorization may be subject to being disclosed again by the recipient and that this information will no longer be protected by federal privacy regulations. I understand that my health care and payment for my healthcare will not be affected if I do not sign this form. I understand that I may see and copy the information described in this form, if I request it. This form was completely filled in before I signed it. I certify that all of my questions were answered to my satisfaction and that I understand this authorization form and all of its contents.
I acknowledge that I was provided a copy of the Notice of Privacy Practices from Advanced Podiatry and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices.
I acknowledge that email provided is safe and will only be used by our office and never distributed or shared with other parties. This office has the right to use any email or phone number provided by you to contact you for any and all communications deemed necessary including appointment reminders and other communications from time to time.
I hereby voluntarily consent to outpatient care by the podiatrists at Advanced Podiatry, encompassing routine care, diagnostic procedures, examination and medical treatment including, but not limited to, minor surgical procedures, routine laboratory work, x-rays, ultrasound and administration of medications and injections prescribed by Advanced Podiatry. I agree to ask questions to clarify treatment should I not understand the treatment plan.
INSURANCE ASSIGNMENT AND RELEASE
I certify that I have insurance with the insurance company(ies) disclosed and assign directly to Advanced
Podiatry all insurance benefits, if any, otherwise payable to me for service rendered. I understand that I am
financially responsible for all charges whether or not paid by my insurance. I authorize the use of my signature
on all insurance submissions. If I have an HMO, I will inform Advanced Podiatry and understand that I am responsible for full payment.
Advanced Podiatry may use my health care information and may disclose such information to the above-named
insurance company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services
I request that payment of authorized Medicare benefits, and if applicable, Medigap benefits, be made either to me or on
my behalf to Advanced Podiatry for any services furnished to me by that provider. To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare Services. My Medigap insurer and their agents any information needed to determine these benefits for related services.I understand that any deductibles, coinsurance, denied or non-covered services are my responsibility.This form has been explained to me and I fully understand this Consent to Treatment and agree to its contents