Hipaa Release Form

Please correct the errors described below.

I hereby give my permission to disclose personal information about my treatment to the following individuals: (Example: Spouse, parent/legal guardian, friend, etc.) We may only give information to listed individuals (including parents & spouses). If no one is listed Access Dermatology CANNOT give any information about you.

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(Or Parent/Legal Guardian of Minor)

I have read and agree to the Notice of Privacy Practices provided to me by Access Dermatology, PC.

(Or Parent/Legal Guardian of minor)

I have read and agree to the Financial Policy provided to me by Access Dermatology, PC.

AUTHORIZATION AND CONSENT TO TREAT

I, the undersigned, authorize Mary Mather, MD to provide medical care to me or my minor dependent. I, the undersigned, authorize release of any medical information or other information necessary to process insurance claims for myself or my minor dependent. I, the undersigned, request that payment of authorized Medicare and/or other insurance benefits be made, for me or on my behalf, to Access Dermatology, PC, for any services furnished by that physician/provider. I authorize any holder of medical information about me to release to my insurance carrier and/or the Center for Medicare and Medicaid Services and its agents any information needed to determine these benefits are payable for related services.

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.

(Or Parent/Legal Guardian of minor)

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