Patient Consent for Disclosure of Information

Please correct the errors described below.

I have read the Notice of Privacy Practices and have had any questions answered by this office. I understand that by signing this form, I consent to the following:

  • Sharing Information For Purpose Of Treatment: You will share information with all members of my treatment team, both within this office and with our providers (personal and institutional) in order to provide me with quality care and educational/wellness programs specified in my insurance plan;
  • Sharing Of Information For Purposes Of Payment: You will share all necessary information with my insurer(s), payor(s), governmental entities (such as Medicare, Medicaid, etc.) and their representatives involved in the billing process (including, but not limited to) claims representatives, data warehouses, billing companies;
  • Sharing Of Information For Purposes Of Operations: You will share all information necessary for ongoing operations of this office, including (but not limited to) the credentialing process, peer review, accreditation and compliance with all federal and state laws.

My consent is freely given. I understand that I may revoke this consent at any time if that revocation is in writing, but any disclosures given in reliance on this prior consent will be permissible.

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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