I consent to examination, treatment and procedures, which may be performed during office visits including emergency treatment considered necessary by the physician and/or her designated provider.
Authorization for Release of Information/Receipt of Notice of Privacy Practices/Written Acknowledge form:
I authorize Ideal Gynecology to release to my insurance carrier and its designated agents any medical information, including information related to psychiatric care, drug or alcohol abuse, and HIV/AIDS, necessary to process any healthcare related utilization review or quality assurance activities. I further authorize the release of any medical information to any other providers to whom and from whom I have been referred for healthcare services or who provide consultative services regarding my medical care. This authorization shall remain in effect until revoked by me in writing. I know that I have a right to receive a copy of this authorization upon request and agree that a photocopy of same is as valid as the original
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