Release of Information. I authorize the release of any and all information required by my insurance company from records in the possession of Aubrey K. Ewing, Ph.D. & Associates, P.A. for the purpose of securing payment for services. I understand that due to the requirement to release certain protected health information to insurance companies and managed care organizations in order to secure payment, that there are limits to the confidentiality of information I provide to this office. I understand the this office will release only the information necessary to secure payment for services.
Appointment Contract. If, for any reason, I cannot keep a scheduled appointment with this office, I will give at least 24 hours advanced notice of the cancellation. I understand that if I fail to keep my scheduled appointment without proper notification, that I may be responsible for payment of the full amount of the office visit charge.
Assignment of Benefits. I hereby assign all major medical and mental health benefits to which I am entitled including Medicare, private insurance, and any other health plan to Aubrey K. Ewing, Ph. D. & Associates P. A. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize Aubrey K. Ewing, Ph.D. & Assoc., P.A. to release only information necessary to secure payment.
HIPAA Disclosure. I acknowledge that I have read and understand the HIPAA disclosure describing the procedures of this office regarding my protected health information (see HIPAA Disclosure here).