Patient Registration Form / Medical Privacy Notice (HIPAA)

RESPONSIBLE/ INSURED PARTY INFORMATION:

EMERGENCY CONTACT INFORMATION:

Payment is required for all services at the time they are rendered. If your visit is provided under contracted insurance coverage, all co-payments, co-insurance, and deductibles are due at the time of service. Any account balances are delinquent after 30 days. Delinquent accounts will incur a monthly billing fee of $10 or 1.5%, whichever is greater. In addition to understanding the billing policy, I assign all insurance benefits and additional payer benefits to Carson Dermatology for services provided by them. I authorize release of medical information as necessary for insurance claims, applications, and prescriptions, and I authorize release to my primary care physician, referring physicians, as well as consultants, as needed.

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.

Medical Privacy Notice

HIPAA

Health Insurance Portability Accountability Act

In 1996, Congress passed a series of legislative acts designed to assure the security and confidentiality of medical records and information. This legislation is collectively known as HIPAA. All medical facilities and providers are required to comply with these requirements as of April 14, 2003.

Permitted uses and disclosures of your medical information:

1. Treatment, Payment, and Healthcare Operations
2. To communicate with your other physicians and healthcare providers
3. To communicate with your insurance company for authorization and payment purposes
4. Under rare circumstances, to comply with court orders, police, or national security directives
5. To comply with public health directives laws and regulations

Other disclosures or uses of your personal health information, PHI, require your written permission.

You are entitled to:

1. Inspect, copy, or amend your medical information
2. Restrict the use of your medical information by informing us in writing
3. File a written complaint with the office if you feel your medical privacy rights have been violated

We are additionally required to:

1. Post a copy of our privacy policy in the waiting area
2. Maintain a written privacy policy for the practice and provide you with a copy upon request
3. Request that you read and sign a copy of this notice which will be placed in your chart
4. Provide you with the information required to file a privacy complaint with our office or with the federal Office of Civil Rights, OCR, on request

acknowledge I have been given this form, offered a copy of the privacy policy, and had the opportunity to ask any questions.

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.

FOR OFFICE STAFF ONLY

The patient declined to sign and /or review or acknowledge this form.

HIPAA DISCLOSURE AUTHORIZATION

HIPAA regulations require we keep your health information confidential. You do have the right to grant access to this information to family, significant other, or any other person; please complete this authorization.

Please list those individuals to whom you authorize the release of your health information. (ie: medical condition, diagnosis, test results, appointments, and other pertinent health reports.)

This authorization is valid for 3 years.

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.