Patient Information Form - English

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

I authorize Digestive Medicine Associates to disclose my protected health information to:

Authorization for Release of Medical Records:

I hereby authorize payment directly to Digestive Medicine Associates of benefits due to me from my Insurance Company otherwise payable to me. I further authorize the release of any medical information required by my insurance carrier(s) and to any Healthcare Provider involved in my treatment upon written or oral request of such provider. A copy of this authorization may be used in lieu of the original. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers of any information needed for this or a related Medicare claim.

I understand that I am fully responsible for the payment of all charges that are not covered and paid for by the insurance. I further understand that I shall be wholly responsible for all collection charges. This includes Court cost reasonable attorney fees incurred in any attempts to collect delinquent unpaid charges and all charges shall accrue interest at the rate of eighteen percent (18%) per annum from he initial billing date.

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.

Notice of Privacy Practices Summary

Effective April 1, 2003

You have our pledge and commitment to protect your medical information. We understand that medical information about you and your health is very personal. In fact, we are required by law to protect the privacy of your medical information and to provide you with a Notice of Privacy Practices, which describes:

How Medical Information about You May Be Used and Disclosed and How You Can Access This Information.

We are required by law to have your written authorization before we use or disclose to others your medical information for purposes other than providing or arranging for your health care, the payment for or reimbursement of the care hat we provide to you, and the related administrative activities supporting your treatment.

We may be required or permitted by certain laws to use and disclose for other purposes without your authorization.

You also have important rights, which include:

• The Right to Inspect and copy the Protected Health Information (PHI) we maintain about you.
• The Right to request restrictions of your Protected Health Information (PHI)
• The Right to request to receive confidential communications from us by alternative means or at an alternative location
• The Right to request an amendment of Protected Health Information (PHI)
• The Right to receive an accounting of certain disclosures we have made of your Protected Health Information (PHI)
• The Right to complain if you feel your rights have been violated

We have available a detailed Notice of Privacy Practices which fully explains Notice from time to time and a copy is available by calling our office. You have a right to receive a copy of our most current notice in effect. If you have any questions, concerns or complaints about the Notice please contact our Privacy Officer at (305) 822-4107 or via fax at (305) 822-5086

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that under the Health Insurance Portability Act of 1996 (HIPAA) that I have certain rights to privacy regarding my protected health information. I understand that the information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among multiple health care for providers who may be involved in my treatment directly or indirectly.
• Obtain payment from third party payers
• Conduct normal healthcare operation such as quality assessments and physical certification

I have received a summary of Digestive Medicine Associates Notice of Privacy Practices but know that I can contact their Privacy Officer to obtain a detailed Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information.

I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request n writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree that you are bound to abide by such restrictions.

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.

Patient Financial Consent

Deductibles may be applied either to Digestive Medicine Associates (Physician Practice), The Palmetto Surgery Center, Gulfstream Anesthesia Group or Digestive Medicine History Lab creating an overpayment.

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.

Consent to Text and E-mail Communication

We now have the ability to email and/or text you, regarding various functionalities of our healthcare record system.

I consent to receiving appointment reminders and other healthcare communications/information from Digestive Medicine Associates. I understand that this consent includes authorization for the communication of Protected Health Information via text message and/or email.

I understand that this request to receive emails and/or text message will apply to all future appointment reminders/feedback/health information unless I request a change in writing.

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.

**The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plan and details).