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  • In case of emergency

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  • Primary Insurance

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  • The above information is true to the best of my knowledge. I understand that if you participate with my insurance, I am respohnsible for paying my co-payment and any unpaid balance while I am here. you will ask me to pay for this after my visit. If you do not participate with my insurance, I will be required to pay the full visit charge while I am here. I understand that you accept cash, check, MasterCard, Visa, American Express, and Discover as a form of payment.

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  • Patient Consent

    New patient consent to the use and disclosure of health information for treatment, payment or healthcare operations.

  • I, , understand that as part of my health care, Leriche Louis DNP and/or associate orginates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:

    A basis for planning my care and treatment

    A means of communication among the many health professionals who cotribute to my care.

    A source of information for applying my diagnosis and surgical information to my bill.

    A means by which a third-party payer can verifiy that the services billed were actullay provided.

    A tool for routine health care operations such as assessing quality and reviewing the competence of health care officials.

    I understand and have been provided with a "Notice of Privacy Practices" that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

    The right to view the notice prior to signing this consent.
    The right to object the use of my health information for directory purposes.
    The right to request restrictions as to how my health inforamtion may be used or disclosed to carry out treatment, payment or health care options.

    I understand that Leriche Louis DNP, is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign the consent, this organization may refuse to treat me as permitted by Section 164.506 of the code of Federal Regulations. Should Leriche Louis DNP change their notice to the address I've provided.

    I authorize disclosure of my health inforamtion in the following methods:

  • I understand that as part of this physician's treatment, payment, or health care operations, it may be necessary to disclose my protected health information to another entry, and I consent to such disclosure for these permitted uses, including disclosures via fax.

    I fully understand and accept/decline the terms of this consent.
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