ALL AUTHORIZATION MUST BE SIGNED BY THE PATIENT OR BY THE NEAREST RELATIVE IN CASE OF A MINOR, OR WHEN PATIENT IS PHYSICALLY OR MENTALLY INCOMPETENT.
Medical or Surgical Permit:
I, the undersigned or authorized party, hereby consent to medical or surgical procedures, x-rays, drugs (oral and/or injectable), and supplies which treating physician assistant deem necessary. I understand that there are inherent risks with any of these procedures.
Authorization for Release of Physician Responsibility:
If I should leave before completing my medical or surgical procedures, examinnations, or treatment, I hereby release said physician physician assistant and Elite Health Center of any responsibility of medical condition.
Consent for Release of Medical Information:
I hereby authorize Elite Health Center to furnish any representative of the insurance company(s) under whose policy of insurance I am entitled to benefits for the payment of expenses of my medical treatment by the clinic with any information desired by said company(s) for the completion of any claims.
I hereby authorize Elite Health Center to furnish to any facility to which I am transferred any information as may be deemed necessary by the clinic. I hereby release the clinic from all legal liability of responsibility that may arise from the release of such records.
I hereby authorize payment directly to the physician of any insurance benefits otherwise payable to me for this period of treatment.
I understand that I am financially responsible to the clinic for changes not covered by this authorization.
I have been advised of the required privacy practice regarding my medical records as mandated by HIPPA regulations.
A complete copy of the policy has been made available to me. Because of privacy, we must have your approval to discuss your medical condition with members of the family.
Authorization to Release Information:
Elite Health Center may disclose all or part of these records to insurance company, State or Federal Government as may be necessary for the completion of all clinic claims. I understand that the information to be released may include information pertaining to mental or psychiatric related conditions and or drug/alcohol abuse. A copy shall be as valid as the original.
I hereby authorize use or disclosure of the following PHI about me as described below to the following person(s):
THIS AUTHORIZATION REMAINS IN EFFECT UNLESS REVOKED IN WRITING
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.