New Patient Form 2019

Please correct the errors described below.

CONSENT FOR TREATMENT - This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office. You have the right to discuss the treatment plan with your physician or designated provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Person authorized to discuss care:

Emergency Contact (Living with you)

Emergency Contact (Not living with you)

PRIMARY INSURANCE:

SECONDARY INSURANCE:

Authorization for Release of Information/Receipt of Notice of Privacy Practices/Written Acknowledge form: I authorize Ideal Gynecology to release to my insurance carrier and its designated agents any medical information including information related to psychiatric care, drug or alcohol abuse, and HIV/AIDS, necessary to process any healthcare related utilization review or quality assurance activities. I further authorize the release of any medical information to any other providers to whom and from whom I have been referred for healthcare services or who provide consultative services regarding my medical care. This authorization shall remain in effect until revoked by me in writing. I know that i have a right to receive a copy of this authorization upon request and agree that a photocopy of same is as valid as the original

DISCLAIMER: By typing your name above, 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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