ALL PATIENTS MUST PROVIDE THE FOLLOWING INFORMATION
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Have you ever been diagnosed or treated for any of the following:
Assignment of insurance benefits***Authorization to release information***:
I hereby authorize direct payment of surgical/medical benefits to Patricia McCormack, M.D. for services rendered by her in person or under her supervision. I understand that I am financially responsible for any balance not covered by insurance. I also authorize Dr. McCormack to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payments of authorized benefit be made on my behalf. If the co-pay is not paid at the time of the visit, there will be a $10.00 surcharge. *It is your responsibility to obtain a referral, if required, from your primary care physician. If a referral is not obtained, you will be responsible for all charges pertaining to your visit.
REQUEST FOR LIMITATIONS AND RESTRICTIONS OF PROTECTED HEALTH INFORMATION
PATIENTS PLEASE NOTE: The practice is not required to agree to your request. Please see our notice of privacy practices for more information regarding such requests.
Please mark where you DO NOT want us to contact you:
**PAYMENT AND/OR CLAIMS MAY BE DENIED IF CERTAIN INFORMATION IS RESTRICTED TO YOUR INSURANCE COMPANY**
ACKNOWLEDGEMENT OF PRIVACY PRACTICES
I ACKNOWLEDGE THAT I WAS PROVIDED OR OFFERED A COPY OF THE NOTICE OF PRIVACY PRACTICES AND THAT I READ (OR HAD THE OPPORTUNITY TO READ IF I SO CHOSE) AND UNDERSTAND THE NOTICE
This acknowledgement shall remain valid for a period of six (6) years from date of signing. If you would like to review, read, or take a copy of the notice of privacy practices, please ask a member of Dr. McCormack’s staff.
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