Billing/ Testing/Healthcare Professionals/Photography

Authorization for

Billing/ Testing/healthcare Professionals/Photography

for all Services Rendered

To Receive Services:

I give permission for myself or the below referencedpatient to receive health services as indicated. I understand that my or the below patient’s medical records are strictly confidential. I hereby authorize use of these records in provision of services by River Region Dermatology and Laser, PC. I understand that these records may be used for statistical audit purposed without using the name of the patient.

Healthcare Professionals

River Region Dermatology and Laser, PC supports training of healthcare professionals. I understand and agree to be interviewed, examined or counseled with a student present when receiving services.

Routine Testing

I understand that routine testing may be needed to determine what treatment, counseling or referral may be required.

Photography

I consent for medical photographs to be taken of me by Dr. Porcia Love or a representative. I understand that the information may be used in my medical record, for purposes of medical teaching, or for publication in medical textbooks or journals. By consenting to these medical photographs, I understand that I will not receive payment from any party. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize

me.

Refusal to consent to photographs will in no way affect the medical care I will receive. If I wish to withdraw my consent in the future, I may do so with a written request. I authorize the use of these images: (Please initial indicating YES or NO below)

______YES ______NO For use in my medical record.

______YES ______NO For demonstration purpose including an office photo album.

______YES ______NO On our website for prospective patients.

______YES ______NO In print advertisements and/or professional journals.

By signing this form below, I confirm that above information has been explained to me in

terms whichI understand.

Patient or Guardian Signature: ______Date ___/___/___