I authorize CHARM CITY HEALTHCARE, LLC to apply for benefits rendered. I request payment from my insurance company to be made directly to them. I certify that the information I have reported concerning my insurance coverage is correct. I further authorize the release of any necessary information, including medical information for this or any related claims. I permit a copy of authorization to be used in place of the original. The authorization may be revoked by me at anytime in writing. I understand that nothing herein relieves me of the primary responsibility and obligation to pay for medical services provided when a statement is rendered.
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.
Patient Information
Request Release Information From
I hereby authorize you to release Charm City Health Care, LLC a copy of my medical records to be used for continuing medical care. I reserve the right to revoke the authorization in writing at any time. I further agree and understand that this protected health information may be re-disclosed by the recipient and thus, no longer protected under privacy rules.
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.
OBJECTIVES:
The management of all patient information in the strictness of confidence.
CONFIDENTIAL ISSUES:
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.
Please be advised that your signature is valid for six (6) years unless written notification has been submitted to DR. PANKAJ KHETERPAL.
PLEASE NOTE: This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized us to do so.
Medications (list all medications you are taking regularly. Include over the counter, herbal or natural remedies.)
Operations (Please list any surgery and approx. year)
Hospitalization in the last 12 months (other than surgeries)
Father
Mother
Brother or Sister
Please indicate those items that have been a recurrent or a recent significant change.
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.
Your information will be encrypted.