Acknowledgement of Receipt of Notice of Privacy Practices
To Our Patients:
In accordance with Federal Law on the Patient Privacy, please read the following:
medical record information confidential and will use it only for treatment, payment and healthcare operations. The office may release information to other doctors during emergencies, or cases of
neglect and abuse. Our policy identifies your rights to access your records, request restrictions on who can see and be informed of your medical information. In short, to keep your communications
with this office confidential.
You have my permission to release my medical information to the following: (please check and list name and phone number)
(optional, unless needed for insurance billing purposes please complete)
(we would like photocopy of all your insurance cards)
I hereby authorize my insurance benefits to be paid directly to the physician and I understand that I am financially responsible for all non-covered charges. Payment is due and payable at the time services are rendered. I understand that my credit card is on file and that any remaining balance I owe may be charged to my credit card. I also authorize my physician to release any information to my insurance company for the processing of my insurance claims. HMO patients who do not have prior authorization to see Dr. Onuma or Dr. Lee will be financially responsible for any charges incurred.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your message will be encrypted and can only be read by Peninsula Gastrointestinal Specialists, Inc.