I give my consent to the provider and his or her agents to use or disclose my Protected Health Information to carry out treatment, payment, or health care operations. These individuals and entities can release, use, or disclose my PHI to other physicians, nursing practitioners, physician assistants, students in each of the above disciplines, and other such entities or persons as are deemed related to treatment, payment, and health care operations, as determined for the sole discretion of the provider and his or her respective agents. If another provider who is involved with treatment, payment, or health care operations relating to my care requests my medical records, I consent to release my entire medical record maintained by North American Partners in Pain Management, LLP to those requesting providers.I agree, as part of this consent for payment operations, that the provider, its group, their billing personnel, billing agents or Management Company can disclose billing information to any person that calls the provider with billing questions, as long as that person is able to provide the correct social security number and health plan information.I agree that the provider, their agents, or their representatives may call and leave a voicemail message at my home or other number I have provided regarding medical appointments, billing or payment issues, or other information related to treatment, payment, or healthcare operations.I agree that the provider may discuss my PHI with any person that accompanies me to any appointment.The provider may rightly assume that if another person is with me, I have no objection to disclosure of my PHI to that person. I also agree, that the provider may discuss my PHI with any person that identifies him or herself as active in my mental, physical, emotional, or spiritual care, including but not limited to family, friends, clergy, and patient advocates. I also agree, that the provider and his or her agents may disclose my PHI to employers who arrange and pay, directly or indirectly, for my medical treatment.I agree that the provider and their agents may discuss my child’s PHI with the person accompanying the child. I agree that the provider may discuss PHI with both natural parents and stepparents. I acknowledge that state law may grant my child certain privacy rights regarding their PHI and that I have no right to receive this information. I agree the provider and his or her agents may, upon request, disclose my PHI to public health agencies, law enforcement, and the FDA.I acknowledge that I have received a copy of a separate document entitled “Notice of Privacy Practice”which sets forth my rights regarding privacy of my PHI.
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, Blue Shield, HMOs and commercial insurance to North American Partners in Pain Management, PLLC.North American Partners in Pain Management, PLLC will bill only for the professional component of these services.I understand that I am financially responsible for all charges for the hospital and for anesthesia if these services are used.I understand that I am financially responsible for all charges whether or not covered by said insurance.I authorize release of any information required to secure payment on my behalf.I am aware that there is a $30.00 late cancellation fee for any appointment or procedure that is not cancelled at least 24 hours in advance.I request that any payments of authorized Medicare benefits be made either to me or on my behalf to North American Partners in Pain Management, PLLC, for services furnished to me by the provider.I authorize any holder of medical information about me, to release to the Health Care Financing Administration and its agencies any information needed to determine these benefits or the benefits payable for related services.