Note: By filling out the form online, your name entered in the end would be treated as Digital Signature.
I consent to the use or disclosure of my protected health information (PHI) byLakeview Internal Medicine, P.A., for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills, or to conduct health care operations. I understand that diagnosing or treatment of me by Lakeview Internal Medicine, P.A., may be conditioned upon my consent as evidence by my signature on this document.
I understand I have the right to request a restriction as to how protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Lakeview Internal Medicine, P.A., is not required to agree to the restrictions that I may request, and may request I seek another Internal Medicine physician. However, if Lakeview Internal Medicine agrees to a restriction that I may request, the restriction is binding on the physician.
I have the right to revoke this consent, in writing, at any time, except to the extent that Lakeview Internal Medicine, P.A., has taken action in reliance on this consent. My protected health information (PHI) means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or health care clearinghouse. This protected health information relates to my past, present, or future physical or mental health condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have a right to review Lakeview Internal Medicine P.A., notice of Privacy Practices prior to signing this document. The Lakeview Internal Medicine Center’s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of bills, or in the performance of health care operations. This notice of Privacy Practices describes my rights and the Lakeview Internal Medicine duties with respect to my protected health information.
Lakeview Internal Medicine, P.A., reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of private practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
In an attempt to preserve the confidential nature
of the doctor/patient relationship, it is requested that you complete the information listed below regarding appointments and other administrative matters.
I, the undersigned certify that I or my dependent have insurance with the company listed below and I assign directly to my doctor, all insurance benefits, if any, otherwise payable to me for service rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information to secure the payment of benefits. I authorize the use of the signature on ALL insurance submissions.
Check all of the symptoms that you currently have or have had in the past year.
Have any of your blood relatives had any of the following?
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors that I made in the completion of this form.
How likely are you to doze off or fall asleep in the following situations in contrast to feeling just tired? This refers to your usual way of life in recent times. Use the following scale to choose the most appropriate number for each situation.
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
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