AUTHORIZATION TO RELEASE HEALTH INFORMATION:
I understand that as part of my healthcare, Physicals Plus, originates, maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that my medication history and formulary benefits may be downloaded from a secure electronic clearinghouse. 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/or treatment were provided.
A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
I understand and acknowledge that I received a Notice of Privacy Practices, and I consent to such disclosures as delineated in the Notice.
I understand that this may include information relating to:
Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV)
Behavioral health service/psychiatric care
Treatment for alcohol and/or drug abuse
I understand that I have the following rights and privileges:
The right to review the notice prior to signing this consent
The right to object to the use of my health information for directory purposes
The right to request restrictions as to how information may be used or disclosed to cary out treatment, payment or healthcare operations.
I understand that Physicals Plus 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. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse treatment. I further understand the Physicals Plus reserves the right to change its notice and practices, in accordance with Section 164.520 of the code of Federal Regulation.
I understand that as part of this organization’s treatment, payment or healthcare operations it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosure via fax. I understand and acknowledge that I received a Notice of privacy practices and I consent to such disclosures as delineated in the notice.
ASSIGNMENT OF INSURANCE BENEFITS:
Medicare Certification (if applicable): I certify that the information provided by me in applying for payment under TITLE XVII of the Social Security Act is correct and request on my behalf all authorized benefits.
I hereby, authorize and instruct my insurance carrier to make payment directly to Physicals Plus for benefits (payments) otherwise payable to me. I agree and understand the Physicals Plus will submit claims for treatment to my insurance carrier. I authorize benefits to be assigned to Physicals Plus. I agree to personally pay for any charges that are not covered by or collected from any insurance program, including any deductibles and coinsurance amounts.