Patient Information (Page 3 of 4) in pdf

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS

We promise we will not share your private health information without your

permission AND you give us permission to file your insurance for you.

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history,

symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this

information serves as:

a basis for planning my care and treatment

•

a means of communication among the many health professionals who contribute to my care

•

a source of information for applying my diagnosis and surgical information to my bill

•

a means by which a third-party payer can verify that services billed were actually provided

•

a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

•

I understand a Notice of Privacy Practices has been posted that provides a more complete description of information uses and

disclosures. I understand that I have the right to request my own copy and I have the right to review the notice before signing this

consent. I understand that I have the right to object to the use of my health information. I understand that I have the right to

request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare

operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this

consent in writing, except to the extent that the organization has already taken action in reliance thereon.

Authorization for Release of Medical Information

Alicia W. Grossmann, MD PA

I, _____________________________authorize

to discuss with or release my medical

information with the following:

Spouse: __________________________________________________________________________

Parents: __________________________________________________________________________

Children: __________________________________________________________________________

Other: ____________________________________________________________________________

o As a courtesy to you, our office can file insurance to primary and secondary insurance.

o I authorize the release of any medical information necessary to process my claim and I

authorize payment of benefits directly to Alicia W. Grossmann, MD

I understand that I may revoke this consent, in writing, at any time by submitting written notification to

Alicia W. Grossmann, MD PA, attention Medical Release Correspondent, at the above address.

I hereby authorize Alicia W. Grossmann, MD PA to disclose my medical information as requested.

Information used or disclosed by this authorization may be subject to subsequent disclosure by the

recipient and no longer protected by this rule.

_______________________________

____________________

(Signature of Patient)

(Date)

_______________________________

____________________

(Signature of Parent/ Executor/Legal Representative)

(Date)

Page 3 of 4

Patient Information Page 3

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