Authorizations and Consents

Required *

Date of Appointment

HIPAA Use and Disclosure Authorization

I hereby authorize Circle of Life Family Medicine to disclose my protected health information to the person named below. (DO NOT NEED TO LIST SELF. THIS IS IF YOU WOULD LIKE SOMEONE ELSE TO BE ABLE TO OBTAIN YOUR PROTECTED HEALTH INFORMATION.)

Name and Relationship to Patient

Notice of Privacy Practices

I have been given the opportunity to read a copy of Circle of Life Family Medicine's Notice of Privacy Practices (posted in office). This Notice describes how Circle of Life Family Medicine may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.

I acknowledge that I have read and understand the above privacy statement.

Insurance and Payment Authorization

Should a dispute arise concerning injury related claims, or should this office not be able to verify coverage, the patient is ultimately responsible for payment, regardless of any claims pending.

I hereby authorize Circle of Life Family Medicine to furnish information to insurance carriers concerning my illness and treatments, and I hereby assign to Circle of Life Family Medicine all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by my insurance.

I acknowledge that I have read and understand the above insurance payment statement.

Verification Text