HIPAA Information

Published on June 2016 | Categories: Documents | Downloads: 43 | Comments: 0 | Views: 340
of 1
Download PDF   Embed   Report

HIPAA Information

Comments

Content

HIPAA INFORMATION

Douglas H. Kahn, D.P.M., P.A.
Foot & Ankle Center 2207 Sunrise Blvd. Ft. Pierce, FL 34950 772-464-1985 1696 S.E. Hillmoor Dr., Ste. B Port St. Lucie, FL 34952 772-335-1200 Fax: 772-335-1292 3515 Willoughby Blvd. Stuart, FL 34997 772-288-3223

PATIENT AUTHORIZATION FOR THE USE AND OR DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby authorize Douglas H. Kahn, D.P.M., P.A. (the practice) to use and/or disclose to my Primary Care Physician (PCP), lab, imaging center, insurance company, the following specific protected health information: any/all information needed to provide healthcare services and/or receive payment from my Insurance Company. I understand that this authorization is valid for seven (7) years. I understand that the purpose or use of the disclosure I am granting is for: updating my PCP as to my podiatric health, xrays/office notes needed to send to labs, imaging centers, insurance company, or release of records as may be deemed necessary by Dr. Kahn, his office manager, or myself or legal representative. I understand that the office may or may not receive financial or in-kind compensation in exchange for using or disclosing the health information described above. Financial compensation will be determined per request. I understand that this authorization may be revoked by the authorizer, in writing, at any time. 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. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. I understand that, and consent to, the following appointment reminders that will be used by the Practice: telephoning my home and leaving a message on my answering machine or with the individual answering the phone. I understand that my healthcare will not be affected if I do not sign, however, payment for my healthcare will be affected if I do not sign this form. I understand that by not signing this disclosure that Dr. Kahn retains the right to refuse treatment and that if treated, I will be responsible for healthcare payments and that I will have to seek reimbursement from my Insurance Company on my own. I understand that I may see and copy the information described in this form, if I ask for it, and that I will get a copy of this form upon request after I sign 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 from and all of its contents. This authorization is valid as of (TODAY’S DATE)______________ Print patient’s Name____________________________ Parent/Guardian Name__________________________ Signature__________________________________ Relationship_______________________________

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close