I hereby request and authorize Dr. Kyle Pankonin to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter
This authorization is also intended to include radiographic examination at the doctor's discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child above.
(If applicable) Under the terms and conditions of my divorce, separation, and/or other legal authorization, the consent of a spouse, former spuose, or other parent is not required. If my authority to select and authorize this care should be revoked or modified in any way, I will immediately notify this office.
I have received RRCC's notice of HIPAA Privacy Act. I authorize RRCC to release to my insurance company, health plan, HMO, no-fault carrier, and/or workers' compensation carrier, any information including my complete health record needed to determine benefits for services provided by or on behalf of RRCC. I understand and agree that I am financially responsible to RRCC, for any and all charges not covered by insurance for myself, spouse, and dependents.
I acknowledge the privacy risks associated with using electronic communications and authorize Red Rock Chiropractic Center staff and/or doctor to communicate with me or any minor dependent/ward for purpose of medical advice, education, clinical record summaries, full medical records, and/or appointment reminders. I understand that my e-mail address will not be given to anyone outside of this clinic for any reason and that this will be for medical purposes only.
I, the undersigned, certify that I (or my dependent) have insurance coverage with
and assign directly to Red Rock Chiropractic Center all insurance benefts, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
I request that payment of authorized Medicare benefits be made of my behalf to Red Rock Chiropractic Center for any services furnishd to me. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.
This information may be disclosed to and used by the following organization:
Kyle J. Pankonin, D.C.
Red Rock Chiropractic Center
202 Main Street, PO Box 517
Lamberton, MN 56152
The reason for disclosure of this information is for the following reason:
1. Continued Health Care
I understand I have a right to revoke this authorization at any time yby presenting a written revocation to the medical record department. I understand the revocation will not apply to:
1. Information already released in response to this authorization2. My insurance company when the law provides my insurer with the right to contests a claim under my policy.
I understand authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules.
Unless otherwise revoked, this authorization will expire on the following date, event, or condition:
If I fail to specify an expiration date, event, or condition, this authorization will be in effect for one year from this date, for records generated as a result of services occurring on or prior to this date.