If at any time you wish to change the information provided on this form, please ask for a new form prior to your appointment so your chart can be updated. Please do not hesitate to ask if you have any questions regarding the HIPPA regulations.
In compliance with HIPAA regulations, we are required to have confirmation that you have been offered a written copy of Mitchell Dermatology’s Notice of Privacy Practices. My signature below indicates that I have been given an opportunity to review a copy of Mitchell Dermatology’s Notice of Privacy Practices.
My signature below authorizes the release of medical information to my primary care or referring physician and to process insurance claims/applications, prescriptions, and lab work. The patient information included on this form is true to the best of my knowledge. I herein authorize payment of medical benefits by my insurance carrier to the physician for services rendered when an assigned claim is filed. (TO FILE INSURANCE, YOUR SIGNATURE IS REQUIRED)