General Patient Information

I have reviewed the Notice of Privacy Practices, which explains how my medical
information will be used and disclosed. I understand that I am entitled to receive a
copy of this document.

I authorize the office staff and/or Rebecca L. Dorsett, M.D. to release any or all of my medical information to the following individuals:

Thank you for choosing our office to provide for your gynecological needs. This
informational document outlines what care is covered under a routine medical preventive exam. Please be aware that any item(s) that fall outside of the guidelines below can and will be billed as an additional office visit, of which you may or may not have financial responsibility once your insurance carrier processes the claim.

Preventive Medicine Visits Includes:
· care for yearly gynecological exam, which may or may not require a pap
smear
· care of small problem or pre-existing condition that requires no extra work
· Regular preventive are (e.g., well-child exams) for all age groups
· Labs done in conjunction with your well woman exam, which your insurance
may or may not cover depending on your plan benefits
Excludes:
· Counseling/risk factor reduction interventions not provided with a medical
preventive examination.
· Diagnostic tests and other procedures

If you present in our office for a routine well woman visit but then have the doctor
address a medical concern which involves extra time, counseling, requires a referral, or prescription, then the doctor has met the requirements as outlined by the American Medical Association to bill an additional office visit. Please be aware that our office will bill for these additional services and you will be responsible for whatever portion the insurance assigns to your responsibility. Please do not call our office to request we writeoff any portion of these additional charges as we are not allowed, per our contract with your insurance provider, to make adjustments beyond what has been assigned as our contractual adjustment.

Thank you for your understanding.

Dear Patient.
I am happy to announce that we have a new EMR system and will now be able to
communicate with you via email, text message and voice mail. We will be using this to remind you of your appointments, help you with prescription refills, and give you lab results and educational material. We also utilize a patient portal where you can access your medical information. Please sign below acknowledging and accepting this form of communication.

In order to retrieve your pharmacy records electronically, I need your consent for release of information.
Signing this form gives Rebecca L. Dorsett, M.D. and/or Staff your permission to obtain your pharmacy records electronically.