CPANT Acknowledgement and Authorization Form
Please complete all sections to acknowledge office policies, privacy practices, and authorize insurance and PHI sharing.
Acknowledgement of Office & Financial Policies / Privacy Practices
I have carefully read the office and financial policies of Clinical Pediatric Associates of North Texas (CPANT), understand and agree to the terms and conditions as stated. (Yes or No)
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I have received a copy of the office and financial policies of CPANT. (Yes or No)
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If CPANT files insurance on my dependent(s) behalf, I understand I am financially responsible and agree to pay for non-covered services, co-insurance, co-pays and deductibles. (Yes or No)
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I accept legal responsibility for all expenses in treating the patient(s) named below and understand that payment for services is due at the time they are rendered. (Yes or No)
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I have received a copy of the Privacy Practices. (Yes or No)
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I understand that CPANT reserves the right to modify the privacy practices outlined in the notice. (Yes or No)
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I understand that I can request a copy of the updated Notice of Privacy Practices by calling my physician’s office or requesting a copy in person at my appointment. (Yes or No)
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Patient(s) Name (Acknowledgement section)
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Responsible Party’s Signature (Acknowledgement section)
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Date (Acknowledgement section)
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Month
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Year
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Authorization / Insurance & PHI Sharing
Insurance company(s) as needed to process any claims, to pay CPANT directly for covered medical and/or surgical services.
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The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for CPANT to share my protected health information with:
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Authorized Person 1 - Name
Authorized Person 1 - Relationship
Authorized Person 2 - Name
Authorized Person 2 - Relationship
Authorized Person 3 - Name
Authorized Person 3 - Relationship
Patient(s) Name (Authorization section)
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Responsible Party’s Signature (Authorization section)
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Date (Authorization section)
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Month
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Day
Year
Date
Submit
Submit
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