Patient Information

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Insurance Information

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

Receipt for HIPAA Privacy Notice and Authorization to Obtain or Release Information (MR119)

By providing this authorization I understand that the authorization is voluntary and is being done at the request of the patient. I understand that I may refuse to sign this authorization and my treatment and/or payment obligations will not be affected. I understand that the health information to be obtained or released may be subject to re-disclosure by the recipient of the health information and no longer protected by the Federal Privacy Ruled. I understand that I may revoke this authorization at any time by notifying Hoover Foot Center in writing, but if I do, it will not have any effect on uses or disclosures prior to the receipt of the revocation. I understand that this authorization is for six (6) years until specified otherwise.

I hereby authorize Hoover Foot Center to use, disclose health information as follows:

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PLEASE NOTE THAT CHECKING ANY BOX BELOW MAY RESULT IN THE STAFF AT HOOVER FOOT CENTER LEAVING YOUR PROTECTED HEALTH INFORMATION ON AN ANSWERING MACHINE AT THE NUMBER REQUESTED BY YOU.

My signature below is acknowledgement that I have received a copy of the Hoover Foot Center Privacy Notice (MR100) and that I agree to the conditions stated in the notice.

DISCLAIMER: By typing your name below, 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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