Adler Family Practice (AFP)
Consent for Treatment & Release of Information Agreement
CONSENT FOR TREATMENT: Permission is hereby given to the providers and staff of AFP to provide ordinary and necessary medical examination, diagnosis, and treatment and administer such therapeutic treatment or services that the physician may order. Ordinary and necessary medical care shall include preventive and prophylactic care as well as laboratory tests but shall not include surgery, general anesthesia, laboratory tests for which separate consent is required under the law or other extraordinary procedures.
AUTHORIZATION FOR RELEASE OF INFORMATION FOR TREATMENT & PAYMENT: I consent to the use and/or disclosure of my health information (including the diagnosis or treatment of mental illnesses, or drug or alcohol abuse and/or confidential HIV-related information) to any person or organization for the purpose of treatment, including coordinating my continuing care and as otherwise authorized by law, conducting certain healthcare operations. This authorization includes the release of all medical information to health care providers who are directly involved in my care. I also understand that my medical information will be maintained in an electronic health information exchange network released to and accessible to my health care team. I further consent to the use or disclosure of my health information (including mental illness, or drug or alcohol abuse and/or confidential HIV-related information) to any third parties responsible for payment of services furnished to me by or in AFP. This may include reviewing and/or photocopying and/or electronic release of pertinent health information for the purposes of obtaining payment. In the event that any of the information to be released relates to diagnosis or treatment of mental illness or drug or alcohol abuse and/or confidential HIV-related information, I understand that state and federal law prohibits further disclosure of it without specific written consent of the person to whom it pertains or as otherwise permitted by state and federal law. This authorization shall expire two years from the date signed below, and is subject to revocation at any time except to the extent that action has been taken in reliance upon it, withdrawal of consent shall be addressed in writing to AFP Administration.
FINANCIAL AGREEMENT: I owe and agree to pay AFP for any and all charges not actually paid by insurance benefits, including those charges not covered by my insurance policy and those charges that my insurance company deems to be medically unnecessary. If my account is not paid, I will pay all collection costs incurred by AMC to collect the balance owed.
HIPAA Acknowledgement: The undersigned hereby acknowledges that I have received a copy of AFP’s Notice of Privacy Policy and I understand how my protected health information (PHI) may be used and disclosed, my PHI privacy rights, and AFP’s obligations concerning the use and disclosure of my PHI. I authorize AFP to take and use a digital photograph solely for the purpose of personal identification and to enhance my care. This photograph is stored in the medical record, and as such is HIPAA protected information.
By signing, Icertify that I have read, understand, and agree to these terms:
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Signature (Patient or Legal Guardian) Date
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Witness
Rev. 12.17.17