Authorization to Release Health Information

Similar documents
425 North Wendover Road Charlotte, NC Birthdate: Social Security #: Male Female

First Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone:

Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other

TILAK PEDIATRICS Patient Information Form For all Patients 18 years of Age and Older

Billing Address for responsible party (if different from home): Subscriber: DOB: Employer:

Ra m sd ell P ed iatrics, I nc.

Carolina Dental Alliance

Trinity Family Physicians

PATIENT INFORMATION PATIENT INFORMATION. Middle Initial: Nickname: Date of Birth: Marital Status: Address: City: State: Zip Code:

Bozart Family Dentistry

Our portals are encrypted and password-protected, too, so health data remains secure.

All About Kids Pediatric Dentistry

Permission Letter. Patient Name(s):

Need help with frequent crisis, housing, transportation?

Accessible, Affordable, Quality Patient Centered Medical Home

PATIENT INFORMATION INSURANCE INFORMATION

AUTHORIZATION for USE and/or DISCLOSURE of PROTECTED HEALTH INFORMATION

Welcome To. Concord Pediatric Dentistry. First Middle Last. Street City State Zip. Dental Insurance Information

Would you like to receive s with special offers from Carolina Vein Center? yes no

Child s Name Date of Birth. Address. City State Zip. Father s Name Phone (home) Phone (cell) Address. City State Zip.

Consent for Services and Financial Policy

Green Valley Ranch Medical Clinic & Urgent Care. Patient Information Form

Consent for Purposes of Treatment, Payment and Healthcare Operations

PATIENT REGISTRATION FORM

Acknowledgement That You Have Received Our HIPAA Privacy Notice

Patient Registration

Financial and Insurance Agreement

FINANCIAL POLICY. General Information

Permission to Discuss Medical Information HIPPA PATIENT ACKNOWLEDMENT. Patient Name:

WELCOME TO OUR PRACTICE

New Patient Paperwork

PHARMACY INFORMATION

2460 India Hook Road, Suite 106 Rock Hill, SC Tel: (803) Fax: (803)

Patient Name: DOB: Sex: Male/Female. Primary Address: Home Phone: Mobile Phone: Address: Emergency Contact Name and Phone Number:

Baldwin Counseling Payment Agreement

Parkway Dental of Clinton Matthew K. Chow, D.D.S. 401 Clinton Parkway, Clinton, MS Patient Information:

Connecticut Asthma & Allergy Center LLC Registration Form

creating beautiful smiles

Ottesen Family Dentistry * Dr. Pamela Ottesen, DMD * *

PATIENT REGISTRATION

Past Medical History

BROKEN APPOINTMENT/LATE PATIENT POLICY

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 2013 Murphy Dental 608 East Harmony Road, Suite 301 Fort Collins, CO 80525

HAMILTON FOOT AND ANKLE CARE, LLC 9865 E. 116 th St. #300 Fishers, IN (317)

Insurance Information My Plan is a: PPO HMO POS (Point of Service) Other. Patient Name Address City State Zip

PATIENT REGISTRATION INFORMATION FOR MINORS

Mother s Name: Birth date: SSN: Home Address: City State Zip Home Phone# Work # Cell # Address Employer

CREEKSIDE DENTAL REGISTRATION FORM. Please Print PATIENT INFORMATION. Patient s Last Name: First: Middle:

The Pediatric Center of Stone Mountain, LLC. General Pediatrics, Adolescent Medicine & Behavioral Health Services

PAYMENT AGREEMENT BROKEN APPOINTMENT INFORMATION

Date How did you hear about Shine? P A T I E NT I N F O R M A T I O N

Sparta Dental Center Office Policy Statement

New Beginning Pediatric Rehab ~ Maryland s Trusted Rehabilitation Practice ~ (410) Office (877) Fax

Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA

Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone

Is this your child s first visit to the dentist? Yes No If no, date of: last exam dental x-rays fluoride treatment

Center for Emotional Wellness & Healing, LLC 100 Heritage Valley Rd, Ste. 1, Sewell, NJ 08080

M F Last Name First Name Middle Initial Gender. Home Phone: Work Phone: Cell Phone: Physical Address: Mailing Address (if different):

Patient Safety and Privacy. Appointment Policy

Important Facts Regarding Our Practice

DFW Pediatric Neurology

LAS VEGAS ENDOCRINOLOGY

INFORMATION FORM. Page 1 of 17

Patient Name: First Middle Last Address: Number Street (Apt#) City State Zip Address: Okay to Statement? Yes No

GETTING TO KNOW YOU. 1. How important is it for you to keep your teeth healthy for a lifetime?

Patient Registration Forms

Patient Dental History

NEW PATIENT PACKET includes the following forms:

New Patient Registration Form. New Patient Update Date: / /

Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications

Today s date: PATIENT INFORMATION. Address:

NAME OF PATIENT DATE OF BIRTH DATE ADDRESS PHONE (HOME) PHONE (CELL) INSURANCE INSURANCE INSURANCE NAME ID# GROUP#

Patient Registration

FILING- THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYMENT IN FULL OF THEIR ACCOUNT, NOT THE INSURANCE COMPANY.

Policies and information:

Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax:

Long Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.

PEDIATRIC PATIENT REGISTRATION GALEN MEDICAL GROUP, PC

2018 REGISTRATION FORM HIGHLIGHTED AREAS REQUIRED (Please Print Clearly)

REGISTRATION FORM. Today s Date: / / Previous PMD: PATIENT INFORMATION NAME: DOB: / / GENDER: NAME: DOB: / / GENDER: NAME: DOB: / / GENDER:

WOMEN S PREMIER OBGYN REGISTRATION FORM

PATIENT TREATMENT AGREEMENT

PSYCHOLOGICAL SERVICES AGREEMENT

Patient's Name: Date of Birth:

Office and Financial Policies

Patient's Name: Date of Birth:

PEDIATRIC PATIENT INFORMATION

Center for Speech & Language Pathology, LLC

Acknowledgement of Privacy Practices

Acknowledgement of Privacy Practices

Welcome to Thurston Medical Clinic

Who referred you to us? Who shall we contact in case of emergency? Phone:

Minor Registration Forms Please Print Legibly. Demographics. *Patient Last Name: *First Name: Middle Initial:

PATIENT REGISTRATION

HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION

Please print and complete all the enclosed forms and bring them to your first appointment.

Welcome to Pediatric Dentistry of Greenville!

CRG PATIENT REGISTRATION FORM

PSYCHOLOGICAL HEALTH ASSOCIATES, PA PSYCHOLOGIST-PATIENT SERVICES.

CRG PATIENT REGISTRATION FORM

Transcription:

Authorization to Release Health Information Patient Information: Name of Patient Date of Birth Address City, State, Zip Phone At my request, may release the following information: (Name of the entity) Entire record Financial records Office visit notes Marketing* On site record review by the patient Psychotherapy notes if this box is checked only psychotherapy notes may be released. Diagnostic studies (list): Other as listed *Financial compensation is received for this communication. Entity or person who will receive the information: Name Address City, State, Zip Phone Send the information electronically. Email address: For email communication I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to move forward to allow email communications to occur. This authorization shall be in effect until the information has been forwarded as requested or until the course of treatment is complete. Patient Rights: I have the right to revoke this authorization at any time. I may inspect or copy the protected health information to be disclosed as described in this document. Revocation is not effective in cases where the information has already been disclosed but will be effective going forward. Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I may refuse to sign this authorization and that my treatment will not be conditioned on signing. I understand released information may include a communicable disease diagnosis such as HIV. Date Signature of Patient or Personal Representative Description of Personal Representative s Authority (attach necessary documentation) Revised May 2014

NC Pediatric Dentistry Authorization for Release of Information Compound Release Name of Patient Date of Birth Cabarrus Pediatric Dentistry is authorized to release protected health information about the above named patient in the following manner and to identified persons. Entity to Receive Information. Check each person/entity that you approve to receive information. Voice Mail Other person (s) (provide name and phone number) (i.e. Nanny, Stepparent, Grandparent, Friend, Relative etc.) Email communication -Provide email address* *For email communication to occur, please accept the disclosure below: Text communication Provide number * *For text communication to occur, accept the disclosure below: Description of information to be released. Check each that can be given to person/entity on the left in the same section. Appointment Reminders Financial Treatment Financial Treatment Appointment reminders Breach notification Appointment reminder Other: For email and/or text communication I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to receive email and/or text communication as selected. Photo of patient received by patient or legal guardian Photo taken by staff (Example: pre/post procedure) Other May be posted in office May be posted on website Other Patient Rights: I have the right to revoke this authorization at any time. I may inspect or copy the protected health information to be disclosed as described in this document. Revocation is not effective in cases where the information has already been disclosed but will be effective going forward. Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization will remain in effect until revoked by the patient. Date Signature of Patient or Personal Representative *Description of Personal Representative s Authority (attach necessary documentation) Revised Oct 2014

Financial Policy Thank you for choosing us as your dental healthcare providers. We are committed to providing you with the highest quality care in a compassionate, professional, and timely manner. Payment in full is required at the time of service for non-insured patients. Payment of the estimated portion and or co-pays (or the balance in full if your carrier will not reimburse us directly) is required for insured patients at the time of service. In-house payment plans are available and we also offer patient financing programs through a third party. Any estimate given on any treatment needed is subject to change if additional information is revealed through further clinical examination or radiographs. Once a patient is aware of what is taking place and allows treatment, patient is responsible for payment of additional treatment. Our practice is not a preferred provider for every insurance carrier. We will file any insurance claims as a courtesy to you. Our office will need to disclose your personal information to your insurance for reimbursement. The benefit percentages quoted are based on "UCR" or "usual, customary, reasonable" and are determined by your employer and the insurance carrier. Your dental insurance plan is an agreement between your employer and its selected insurance company. Dental care is provided to the patient, not to the employer, nor to the insurance company. As a result you are responsible for full services payment to NC Pediatric Dentistry. We will accept assignment of benefits to come to us as your provider. Any balance that results from your carrier's denial or deviation from our estimated benefits payments remains your responsibility. Any account for which an insurance claim has been filed and has not been paid after 90 days may be subject to further action by you or full payment by the responsible party. If at that time you do not respond or the responsible party does not make payment, then your account may result in further collection actions as stated below. Any account that remains unpaid after 45 days may incur a collection service fee of $25 and may be turned over to a third party for collection purposes. In case of delinquent or default account, Patient/Responsible Party is liable for any and all collection and/or reasonable Attorney fees. A returned check reimbursement charge of $25.00 or the maximum allowed by North Carolina State law will be issued to any account on which payment has been refused by the payer bank because of insufficient funds or because the drawer did not have an account at that bank. We require a 24-hour notice when canceling or rescheduling an appointment. Our policy for broken or missed appointments follows: For patients who (1) are chronically late, (2) frequently fail to show or (3) chronically reschedule or cancel on the day of the appointment will be put on a call list or possibly dismissed from the practice. By signing below the patient accepts the terms of this financial policy. Patient Name: Patient or Guardian Signature:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Patient Name and Address: I have received a copy of named practice. Signature: the Notice of Privacy Practices for the above For Office Use Only We were unable to obtain a written Acknowledgement of Receipt of Notice of Privacy Practices because: An emergency existed and obtaining a signature was not possible at the time The individual refused to sign. A copy was mailed with a request for a signature. We were unable to communicate with the patient for the following reason: Other Prepared by Signature:

Missed Appointment and Late Arrival Policies In an effort to maximize the time your Dentist spends with you and minimize your wait time, we have made changes to our Missed Appointment (No-Show) and Late Arrival Policies as follows. Missed Appointment (No-Show) Policy Effective immediately, we will implement a missed-appointment policy which will affect ALL patients who do not keep their scheduled appointment or who cancel an appointment with less than a 24-hour notice. First missed appointment within 12 months Patient/parent will receive a letter advising of our policy. Second missed appointment within 12 months Patient/parent will receive a 2nd letter and for future appointments patient will be considered as work in only. After a second missed appointment families will no longer be scheduled together. Third missed appointment within 12 months - Patient/parent will receive 3 rd and final letter dismissing patient from practice. Late Arrival Policy Acknowledgment (initials) Patients arriving more than 10 minutes late for a scheduled appointment will be rescheduled and considered a missed appointment, subject to the Missed Appointment policy above, unless an exception is permitted by the doctor or the schedule allows. Patient Name: Acknowledgment (initials) Parent/Guardian Signature:

Parental Treatment Consent Patient Name and Address: I, parent/legal guardian give the following person(s) permission to accompany my child to dental appointments, allowing them to make financial and treatment decisions on my behalf. I understand that medical history and consent must be updated and signed yearly by a parent or legal guardian. VERBAL CONSENT CANNOT BE ACCEPTED. Person bringing child must be 18 years or older, must be listed below and will be asked to show a valid ID. A child under the age of 18 must be accompanied by an adult listed below. In order to remove someone from this list the parent or legal guardian must come in person with a valid ID and sign a new consent. Person/Relationship: Person/Relationship: Person/Relationship: Signature:

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback