Patient Signature Authorization & Confidentiality Form printable pdf download

Michigan Urological Clinic

Signature Authorization & Confidentiality Form

This authorization form MUST BE SIGNED prior to seeing a physician!

Patient’s Name: __________________________________DOB: ___________Date: ______________

Release of Information

I authorize the release of any medical information necessary including, but not limited to, any and all

information regarding serious communicable diseases and infections as defined by statute and the Michigan

Department of Public Health (i.e. VD, TB, Hepatitis B, HIV, Aids, and ARC), or any alcohol or drug abuse

treatment information, etc.;

1) To process claims:

Information released hereunder may be provided to any independent auditors hired or

retained by any and all third party payers, private health insurers or any employer for the

purpose of enabling these independent auditors to analyze charges made for services

rendered to the patient. This authorization includes authority to fax such information, if

necessary. Moreover, any information released hereunder may be released or

communicated verbally, in writing, or through electronic communication (i.e. via telephone,

mail, fax, e-mail, etc.).

2) To be referred to a specialist for medical care,

3) To obtain services for lab, x-ray, and other diagnostic services. I also authorize that this

information may be faxed, if necessary.

Signature __________________________________Date:____________Relationship:____________

Assignment of Benefits

I authorize that insurance payments of medical benefits be paid directly to Michigan Urological Clinic for the

services rendered.

Signature: __________________________________Date:____________Relationship:____________

Responsibility of Payment

I authorize and accept responsibility for payment of any balance of fee; 1) remaining after payment of

insurance benefits, 2) not covered by insurance for whatever reason, 3) deemed not covered by workman’s

compensation, or 4) deemed not covered by auto insurance.

Signature: __________________________________Date:____________Relationship:_____________

Responsibility of Patient

I am willing to take responsibility for my own health in such matters as weight, diet, smoking, exercise, alcohol

and drug use and in following my doctors’ instructions. I understand that abuse in any of these areas may

adversely affect my health and treatment.

This release shall be effective only as long as is necessary to accomplish the purpose for which it is given or until it is

specifically revoked in writing by the undersigned.

I have read and understand all of the above and agree to the terms set forth by the Michigan Urological Clinic.

Signature: _____________________________ ____Date: ____________Relationship: __________

Patient Signature Authorization & Confidentiality Form