HIPAA Acknowledgment

I understand that I have the right to review the Notice of Privacy Practices of Michigan Pain Specialists, PLLC prior to signing this consent. I understand that Michigan Pain Specialists, PLLC reserves the right to change their notice and practices, and I will be given new notification if this occurs. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations, and the organization 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 understand that I am authorizing the release of all or any part of my medical record for the purposes of treatment, payment, or practice operations. This release may include records containing information regarding the diagnosis and/or treatment of HIV or AIDS, mental illness, and/or drug and/or alcohol addiction or abuse to any person or corporation which is or may be liable under a contract for all or part of the medical charges, including but not limited to: Medicare, Medicaid, or other private or public health insurance programs, reviewing agencies, worker’s compensation carriers, welfare agencies or patient’s employer. The records may be needed in order to process a claim for medical services. I authorize for the release of information needed for billing purposes to entities that may provide services pertaining to my physician visit, such as reference laboratories.

I authorize any holder of medical or other information about me to release Social Security Administration and Center for Medicare and Medicaid Services (CMS) or its intermediaries or carriers any information needed for this or a Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. I understand that it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. (Section 1128B of the Social Security Act and 31 U.S.C. 3801-3812 provides penalties for withholding this information.) Regulations pertaining to Medicare assignment of benefits also apply.