HIP A A OMNIBUS RULE

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT / LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement and authorization. In refusing we may NOT be allowed to process your insurance claims.

Date

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES INTEH FUTURE.

Name *

First Name Last Name

Legal Representative / Guardian

First Name Last Name

Relationship of Legal Representative / Guardian

How do I want to be addressed when summoned from the reception area?

First Name Only Proper Sir Name

Please list any other parties who can have access to your health information: (This includes step parents, grandparents, and any care takers who can have access to this patient's records):

Full Name

Relationship

Full Name

Relationship

I Authorize contact from the office TO CONFIRM MY APPOINTMENTS, TREATMENT, AND BILLING INFORMATION via:

Cell Phone Confirmation Home Phone Confirmation Work Phone Confirmation Text Message to my Cell Phone Email Confirmation Any of the Above

I authorize INFORMATION ABOUT MY HEALTH be conveyed via:

Cell Phone Confirmation Home Phone Confirmation Work Phone Confirmation Text Message to my Cell Phone Email Confirmation Any of the Above

By checking the box below, you acknowledge and authorize that this office may recommend products or services to promote your improved health. This office may or may not receive third party renumeration from these affiliated companies. We, under current HIP A A Omnibus Rule, provide you this information with your knowledge. *

I agree