Protected health information (PHI) will only be released from our practice with a properly executed authorization from the patient or his/her personal representative, except for treatment, payment, or health care operations and as otherwise required by law. Examples of some instances in which are required to disclose your PHI include Public health activities; information regarding victims of abuse, neglect, or domestic violence; health oversight activities; judicial and administrative proceedings; law enforcement purposes, organ donations purposes, research purposes under certain circumstances; national security and intelligence; correctional institutions; and Worker's Compensation.
Womick Podiatry Clinic P.C. will only use or disclose PHI, except as noted above, consistent with the terms of the authorization.
A patient may revoke his authorization to use or disclose PHI at any time but actions taken prior to the revocation are excluded. If authorization is a condition of obtaining insurance coverage, and the authorization is revoked, the insurer may contest a claim under policy.
Authorization must be properly executed by the patient or his/her personal representative. It should include, the date signed, specific PHI to be released or used, to whom this use or release relates, and an expiration date for the authorization.
Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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***MUST BRING INSURANCE CARD TO EVERY APPOINTMENT AND IT WILL BE UPDATED EVERY 6 MONTHS OR IN THE EVENT OF NEW INSURANCE IN THE PATIENT CHART***
and assign directly to Dr. Debra A. Lee all Insurance Benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for the Medicare and Medicaid Services, Signature or Self, Beneficiary, Guardian or Personal Representative.
Please be sure to arrive 15 minutes early for your appointment to fill out any necessary paperwork and to ensure that you will be seen on time.
We look forward to seeing you and please have a happy and healthy day.
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