Assignment of Release and Acknowledgement of Receipt of HIPPA

Consent*
I agree to use electronic records and signatures.
I agree to use electronic records and signatures. I have read and agree to the ELECTRONIC RECORD AND SIGNATURE DISCLOSURE as posted on https://simonfamilymedicine.com/wp-content/uploads/2019/07/Electronic-Record-and-Signature-Disclosure.pdf
ASSIGNMENT AND RELEASE
Name*
First Last
My Insurance Carrier
*
- I certify that I (or my dependents) have insurance coverage with my insurance carrier (listed above) and or the insurance Simon Family Medicine has on my file, and I assign directly to Dr. Simon all insurance benefits, if any, otherwise payable to me for services rendered. I hereby authorize Simon Family Medicine to bill my insurance company and to release all information necessary to secure the payment of benefits. I also authorize the use of this signature on all insurance submission. I understand that my "Private Healthcare Information" will be used according to the Office Policy and Regulations. I understand that I am ultimately responsible for the charges incurred in this office, regardless of the type of insurance that I have. I am also aware of the 1.5% finance charges that may be assessed on my account if over 30 days past due.
Type Name Here To Acknowledge Consent*
Date*
MM slash DD slash YYYY
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
*
- The Health Insurance Portability and Accountability Act (HIPAA) requires us to give you a notice of our privacy practices and to acknowledge your receipt of the notice.
*
- The Notice of Privacy Practices explains how your protected health information may be used or disclosed by us. In addition, it explains your rights with regard to your protected health information, as well as our legal responsibilities.
It is important for us to honor the confidentiality between patient and Simon Family Medicine. Please check your preference(s) below:*
- You may discuss my medical information ONLY with me.
- You may discuss my medical information with the following people:
Name
First Last
Relationship
Phone
Name
First Last
Relationship
Phone
Name
First Last
Relationship
Phone
May we leave your medical information on your voicemail?*
- Yes
- No. Do not leave any medical information on any voicemail.
You may leave medical information (test results, prescription refill information, etc.) on my voice mail at:
Cell Phone
Home Phone
*
- I do hereby acknowledge that Simon Family Medicine has provided me with a notice of its privacy practices or I have downloaded a copy from their website, as required by Federal law (HIPAA) and consent to share my medical information with the above listed.
Is patient a minor child or legally incapacitated?*
- Yes
- No
Name of Patient*
Patient Date of Birth*
MM slash DD slash YYYY
E-Sign: Type Name Here to Acknowledge Consent*
First Last
Today's Date*
MM slash DD slash YYYY
- Note: If the individual listed above is a minor child or legally incapacitated, a parent or legal guardian/representative should sign below on behalf of the individual and list their relationship.
E-Sign: Type Parent/Legal Guardian/Representative Name Here To Acknowledge Consent*
Today's Date*
MM slash DD slash YYYY
Relationship*
Name
First Last

775-777-8008

775-777-8008

Assignment of Release and Acknowledgement of Receipt of HIPPA

ASSIGNMENT AND RELEASE

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES