Patient Registration Form
Patient Employer/School Information
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Primary Health Insurance
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Past Medical History
Reason for Visit
HIPPA Compliance Patient Consent Form
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/ date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or health care operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPPA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the infoemation for treatment, payment, or health care oprations.
By signing this form, you consent to our use and disclosure of protected healthcare information and potentially anonymous usege in a publication.You have the right to revoke this consent in writing, signed by you. However , such a revocation will not be retroactive.
By Signing this for, I understand that:
PROGRESSIVE PODIATRY & FOOT SURGERY
19 WEST 34TH STREET SUITE 608
NEW YORK, NY 10001
Authorization for Use of Signature On File for Claim Authorization
Mark the section "ENROLL'S OR AUTHORIZED PERSON'S SIFNATURE"with the notation "SIGNATURE ON FILE"
This section authorizes:
1. The release of any medical information necessary to process this claim.2. Payment of medical benefits to the undersigned physician or supplier of services described below.
This authorization will remain in force until terminated in writing the enrollee.
Agreement for Doctor to Receive Isurance Checks
I,the undersigned, realize that I may receive checks from my insurance carrier for services that are provided in this office. I understand that it is my responsibility to sign the back of those checks and forward them, along with the Explaination of Benefits(EOB) that is attached to the check andall corresponding pages, tothe above office with in 7 days. If I fail to do so.I will beresponsible for the full amount of the bill plus any interest and legal fees incurred for collecting them.