Authorization Form - Perito Urology

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

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Name

First Last

I authorize the following person to have access to my medical information.

I authorize Dr. Perito and staff to discuss my lab results, pathology results, appointment scheduling and any other matter association with my health, and discuss results over the phone with me.

PATIENT SIGNATURE

PHONE #

Yo autorizo a este persona tener acceso a mi informacion medica. Incluyendo resultados o procedimentos.

Yo autorizo al Dr. Perito y su oficina discutir mi informacion medica como resultados, procedimentos, citas por medio de llamada telefonica al paciente

FIRMA DEL PACIENTE

NUMERO DE TELEFONO

CONSENT FOR TREATMENT

I hereby authorize Paul E. Perito, M.D. and whomever be may designate as his assistants to perform urological, urodynamics and/or imaging examinations, provide urological services and perform other recommended diagnostic procedures and interventions directed by appropriately licensed professionals. If any unforeseen condition arises in the course of the process calling for procedures in addition to or different from those not complicated, I further request and authorize, Paul Perito, M.D. to do whatever is deemed necessary and advisable. The nature and the purpose for these procedures, the risks involved, and the possibility of complications have been fully explained to me. I acknowledge that no guarantee has been made to me as to the results that may be obtained.

POWER OF ATTORNEY

I expressly authorize and give power of attorney to Paul Perito, M. D., P.A. and his billing agent for the signing and completing of any form in the completion of my claims and endorsing any check made payable to me in support of processing or making payment of claims for any charges incurred by me at the office of Dr. Paul Perito. Further, Dr. Perito acknowledges that he is entitled to receive payment for only those charges which are incurred for his treatment and any overpayment will be refunded appropriately and timely.

ASSIGMENT OF BENEFITS AUTHORIZATION

I authorize Paul Perito, M.D., P.A. and his billing agent to release medical records and any information to any insurance company, employer, adjuster, or attorney that will assist in the payment of a claim. I further authorize all hospitals, physicians, medical clinics, attorneys, employers, and insurance company to release any financial or medical information as of and prior and in the future related to this claim. I hereby assign any and all benefits that I am eligible to receive for care rendered to me by Dr. Paul Perito and staff in consideration of this assignment this office extends partial credit. I also request that payment of authorized Medigap benefits be made on my behalf to Paul Perito, M.D., P.A.

MEDICARE LIFETIME AUTHORIZATION AND ASSIGMENT

Lifetime Medicare B signature authorization for services starting date:

I authorize any holder of medical or other information about me to release to the Social Security Administration and Healthcare Financing Administration or its intermediaries or carriers, or to the billing agent of Paul Perito, M.D., P.A. any information needed for this or a related medical claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment.

CONFIDENTIALITY AND PATIENT BILL OF RIGHTS

Individuals with access to your file are those members of the staff of Paul E. Perito, M.D., P.A. directly related to the provisions of your services. There are circumstances when confidentiality will be limited (e.g., court-ordered appearances, intention to injure self or other, child abuse, criminal or civil litigation); otherwise, confidentiality under all other instances will be maintained. I understand the limits of confidentiality and consent as well as accept this agreement.

Patient Signature

Date

WITNESS

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: Patient Giving Consent

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Social Security

SECTION B: To the Patient – Please read the following statements carefully

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of our protected heath information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revision of our Notice, at any time by contacting:

Contact Person: Dr. Paul Perito’s Office

DO NOT RELEASE INFORMATION TO:

You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this consent.

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare.

Name

First Last

Signature

Date

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth:

Social Security:

I request and authorize the following person to release healthcare information of the patient names above to:

Recipient Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

This request and authorization applies to:

* Healthcare information in relation to the following treatment, condition, and date:

* All Healthcare information

Definition: Sexual Transmitted Disease (STD) as defined by law, RCW 70.24 et seq, includes herpes. Herpes simplex, human papilloma virus, warts, genital warts, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL candroids lymphogranuloma venereum, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome) and gonorrhea.

I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

Yes

No

I authorize the release of any records regarding drug, alcohol and/or mental health treatment to the person(s) listed above.

Yes

No

Patient Signature
Your Name
Your Name
Your Name

Date

Patient Name
First Last
DOB:
PATIENT AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION BY SHADOW PARTICIPANT
Dr. Paul Perito / Perito Urology is a urological training facility. Dr. Perito trains physicians, residents, nurses and/or officers who are interested in healthcare, are pursuing careers in the medical field or desire an educational experience. These individuals are referred to as “shadow participants.”

I understand the shadow participant/s has signed a confidentiality statement that provides patient protections in connection with use and disclosure of their health information, in addition to those protections that already exist under state law. Dr. Perito is committed to protecting the privacy or our patients’ health information.

By signing below, I am voluntarily authorizing Dr. Perito to disclose my health information to these medical participants. This authorization extends for all medical services, including evaluations, procedures and surgeries performed in office or at any other facility.

I understand the terms of this authorization and I have had an opportunity to ask questions about the disclosure of my health information.
Signature
Your Name
Your Name
Your Name
Date

Date

Patient Name
First Last
DOB
I understand I have the option of going to my insurance specified lab for venipuncture and lab work, but I have chosen to have my labs drawn at Dr. Perito’s office and agree to pay a convenience / administrative fee of $15. I understand this service will not be billed to my insurer.
Signature
Your Name
Your Name
Your Name
Fecha

Nombre
First Last
Fecha de Nacimiento

Firma del Paciente
Your Name
Your Name
Your Name
Yo entiendo que tengo la opcion de ir a el laboratorio que sugiere mi sugero para el proceimiento de laboratorio pero he decidido que me hagan los analisis en la oficina. Estoy de acuerdo en pagar el cargo de conveniencia / administrativo de $15. Estos servicios no seran cargados a mi aseguradora.