Hipaa Consent Form - Lifespan Health

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PATIENT CONSENT & HIPAA INFORMATION
PLEASE PROVIDE THE RECEPTIONIST WITH A PHOTO ID & YOUR INSURANCE CARD(S)
(Legal) Last Name:
First Name, Middle Initial:
Date of Birth:
PATIENT AUTHORIZATION TO BILL & HIPAA DISCLOSURE
I authorize that payment of authorized insurance benefits be made to LIFESPAN HEALTH for services furnished to me. I
authorize LIFESPAN HEALTH to release to my insurance carrier and its agents any information needed to determine these
benefits or the benefits payable for related services. I understand that I will be directly responsible for any portion
deemed patient liability by my insurance carrier. I further acknowledge the below signature to be mine and to be used
as my “Signature on File” for eletronic billing purposes. I understand this signature will be used indefinitely unless I
revoke this arrangement.
I acknowledge that I am a “self-pay patient” and as such will be responsible for all services rendered to me. I understand
I may qualify for patient assistance but this assistance is in no way guaranteed.
I hereby acknowledge that I was provided with LIFESPAN HEALTH’s Notice of Privacy Practices.
I hereby authorize LIFESPAN HEALTH to release my Protected Health Information to the following individuals:
Name
Relationship
Telephone
I do not wish my Protected Health Information released to anyone.
CONSENT TO TREATMENT & TO OBTAIN ELECTRONIC MEDICATION HISTORY
I request and authorize treatment and services as may be deemed necesary and appropriate by the providers of LIFESPAN
HEALTH. this care may include radiology, laboratory, x-ray, etc.
I authorize LIFESPAN HEALTH to obtain my medication history utilizing an electronic information exchange. I further
authorize LIFESPAN HEALTH to transmit, view, and disclose this information as part of my medical record and treatment.
CONTACT PREFERENCES: I wish LIFESPAN to adhere to the following contact preferences:
Home Phone:
Written Communication:
Ok to leave detailed information
Ok to send information to my home address
Leave only a call back number
Do not send anything to my work address
Work Phone:
OK to send anything to my work address
Ok to leave detailed information
Only send mail to my home address
Leave only a call back number
OK to send my an e-mail:
Pt. Signature:
Date:
We attempted to obtain written acknowledgement of reciept of our Authorization to Release PHI, but it could not be obtained
for the following reasons: ____ Individual refused to sign ____ Communication barriers prohibited obtaining the acknowledgement
____ An emergency situation prevented us from obaining acknowledgement ____ Other (Please Specify) ___________________
Staff Representative Signature
Date

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