AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
PLEASE PRESENT INSURANCE CARDS*** THEY WILL NEED TO BE SCANNED
RELEASE OF INFORMATION
PRIVACY STATEMENT: We protect our patient's information and the records that we have about their health and the services received in our office. We must have your written, signed consent in order to disclose your health information for the purposes of your treatment, the payment of bills, appointment reminder, etc. I have received a copy of the Privacy Notice (HIPPA-164.520). If we refer our patients to another provider or specialist, we may need to share your information with them. Your privacy is protected as only minimum information is shared.
FINANCIAL RESPONSIBILITY: I authorize the release of medical information to insurance carriers concerning my illness and treatment and I hereby Assign to the doctor all payments for medical services rendered to me or my dependent. I understand that I am responsible for any amount not covered by insurance and that I will pay any copay on the date of services rendered unless other arrangements are made.
MEDICARE AUTHORIZATION: I request that payment of authorized Medicare benefits be made to Flint Gastroenterology Associates, PC on my behalf. I authorize the holder of my medical information to release to the HCFA and their agents any information needed to determine these benefits for related services. I understand that HFCA is the government Medicare Agency.
Review of Systems - Please check any current problems/symptoms that apply
Medical History - Please check any of the medical conditions for which you have seen a doctor.
Surgical History - Please check any of the surgeries that you have had.