I hereby authorize the provider(s) to treat my symptoms and apply for benefits on my behalf for any services rendered by her or his order. I request that payments of authorized benefits from Medicare/Insurance company be made directly to my provider. I authorize my provider to release any medical information about me to HCFA/my insurance and its agents, any information needed to determine these benefits or the benefits payable to related services. I authorize the use of this authorization for any of my insurance submissions. I understand that I am responsible for any amount not covered by my insurance company(s). I certify that information that I have reported with regards to my insurance coverage is correct. I permit a copy of this authorization to be used in place of its original. This authorization may be retrieved by either me or my insurance company at any time in writing.
I authorize Above & Beyond Urgent Care to release information contained in my medical record including, but not limited to: all histories, diagnoses, consultations, treatments, services, testing, summaries of physical conditions, contributing factors, complications, prognoses, prescriptions, social histories and/or protected health information which may be available to you. This includes all information about communicable diseases and/or infections which includes HIV and AIDS. This also includes psychiatric, psychological evaluation, testing and substance abuse or social work records.
This information should be released to:
I understand that:
1) My signature indicates that I know what protected health information is being disclosed and what results of this disclosure may be. 2) Treatment is not contingent upon my signing this release. 3) The information disclosed may be subject to redisclosure by the recipient of your information and would no longer be protected by the HIPAA Privacy Rule. 4) I may request a revocation or revision of this authorization or any part thereof, providing the protected health information has not already been released. I must do so in writing and present my written revocation to the Practice. 5) A photocopy of this release may serve as if it were an original. 6) This authorization shall remain in effect until initial date of service or until patient requesting change in agreement.
If you are signing as a parent, guardian, or personal representative of the patient describe the relationship below.
By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records to the physician/facility listed below.
Release my protected health information to:
