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INSURANCE INFORMATION

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INSURANCE INFORMATION

AUTHORIZATION TO RELEASE MEDICAL INFORMATION and ASSIGNMENT OF INSURANCE BENEFITS: I authorize Gregory B. Morris, DPM, LLC, or its representative, to release to my insurance company or its representative any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such medical or surgical care. I hereby authorize that payments for these services be made directly to my physician or supplier.

FINANCIAL AGREEMENT: I understand that I am financially responsible for all charges whether or not paid by said insurance. These include deductible, co-payment, cost-share, and/or non-covered benefits. I also agree to pay a late payment fee of 1% a month on any unpaid balance over 90 days old together with reasonable attorney's fees and collection expensive should the account be referred to an attorney or collection agency. I agree to pay a $10.00 processing fee for each returned check.

I certify that the insurance information I have provided is correct. I permit a copy of this authorization to b\e used in place of the original. This authorization is valid until revoked by me in writing.

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.

MEDICARE PATIENTS ONLY, PLEASE READ AND SIGN BELOW

Dear Patient: Medicare regulations suggest that I, Dr. Gregory Morris, inform you in advance, that some medical services may not be fully covered or reimbursed by Medicare. If in my professional opinion and judgment, the following services are needed in orcl.er to provide to you with the highest quality of care, they may not be completely reimbursed by Medicare:

Routine foot care and medical appliances.
Medicare may not reimburse these services for the following reasons: Non-Covered service.

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.

MEDICAL HISTORY AND QUESTIONNAIRE

FAMILY MEDICAL HISTORY

I understand that my signature is on file authorizing release of my medical records or any other information required to process insurance forms. I also request payment of medical benefits to Gregory Morris, DPM, FACFAS. I give my permission to physicians to administer treatment and to perform such procedures as may be deemed to the diagnosis and / or treatment of my foot / or ankle conditions.

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.

Queen's Physician Office Building II 1329 Lusitana Street, Ste. 802 Honolulu, HI 96813

Queen's West Physician Office Building 91-2139 Fort Weaver Rd. Room 303 Ewa Beach, HI 96706

Gregory B. Morris, DPM, FACFAS, LLC is in the process of implementing ePrescribing in our office.

ePrescribing is a federally mandated initiative that requires all physicians to prescribe in this manner by 2011.

ePrescribing software sends prescriptions over the internet to your pharmacy in a safe, secure way, through the same technology used by credit card companies. This helps protect the privacy of your personal information.

ePrescribing software also lets your doctor see important information - like drug interactions and your prescription history.

The benefit to you:

  • Less confusion over handwritten prescriptions or unclear phone calls
  • Reduced possibility of medical errors
  • Less chance of adverse drug reactions
  • Fewer trips to drop off at the pharmacy
  • A safer, faster, easier way to get your prescription filled

Patient Consent
I agree that Gregory B. Morris, DPM, F ACF AS, LLC may request and use :my prescription medication history from other healthcare providers or third party pharmacy benefit payers for treatment purposes.

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.

Pharmacy Of Choice

Acknowledgement Of Receipt Of Notice Of Use And Disclosures Of Protected Health Information For

GREGORY B. MORRIS, DPM, LLC

I have read the Notice of the Uses and Disclosures of Protected Health Information (the "Notice") that is posted in your office. I was informed that I may also obtain a printed copy of the Notice from your receptionist. I hereby acknowledge that I received from Gregory B. Morris, DPM, LLC a copy of the Notice.

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.

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