MEDICAL INFORMATION & HIPAA RELEASE FORM

I AUTHORIZE MICHAEL C. SPECK, M.D., P.A. TO DISCUSS AND/OR RELEASE MY PROTECTED HEALTH INFORMATION, INCLUDING LABS, TEST RESULTS, DIAGNOSIS AND TREATMENTS DISCUSSED TO THE FOLLOWING PERSONS:

I acknowledge that Michael C. Speck, M.D., P.A. has made available to me a copy of the Notice of Privacy Practices (HIPAA). This notice describes how this office may use and disclose my protected health information. I understand that I can obtain a complete copy upon my request. A copy is also available at gillespiecountyurology.com Your health information has been made available to other health clinics through our EHR Prisma account. To stop this sharing, please put in writing your preference to stop sharing your information. This release of information will remain in effect until terminated by the patient in writing.

QUESTIONS MEDICARE REQUIRES US TO ASK:

ADVANCE DIRECTIVE (PERSON WHO CAN MAKE HEALTH DECISIONS FOR YOU IF YOU ARE UNABLE)

History of Tobacco Use:

History of Alcohol Use:

PLEASE KEEP OUR OFFICE UPDATED ON YOUR CURRENT MEDICATIONS

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.