(Under 18)
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I authorize my insurance benefits to be paid directly to PanCare Health. I also authorize PanCare Health to release any information required to process this claim.
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health, I will inform the doctors at the next appointment without fail. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this organization’s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I also understand that the Patient Rights and Responsibilities are available for my review and that I have responsibilities regarding my care. I understand that:
I hereby authorize PanCare Health, its facilities and treatment centers, its affiliated physicians, dentists, ARNPs, physician assistants and other medical personnel to administer examinations and treatments as deemed medically necessary.
It is the provider's responsibility to ensure that the provider-patient relationship is confidential. Under the requirements of the Health Insurance Portability and Accountability Act (HIPAA), we are not allowed to release any patient information without the patient's consent. If you wish to have your medical/dental or billing information released to a family member, friend, or legal representative, you must sign this form. Signing this form will give consent to release this information to only the persons indicated below. This consent form will not allow PanCare Health to release any other information to these persons. You have the right to revoke this consent in writing.
I authorize/allow PanCare Health to release my medical/dental and/or billing information to the following individual(s):
I have initialed the Notice of Privacy Practices/Patient Rights and Responsibilities and Consent for Treatment. By doing so I acknowledge that I have read all of the aforementioned statements and will abide by the same and if I do not this may disqualify me from receiving care from PanCare Health/Dental Clinic. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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