Consent to Release Information
I understand that protected health information may refer to medical or health information, including prognosis, psychological or mental illness, prescription, laboratory, and other medical results, including HIV tests or diagnosis.
I give my consent for the release of my protected health information for the purpose of treatment, payment, and other relevant health care operations.
I hereby authorize the medical facility to use my medical information for their exercise of rights, title, and interest in the payment from healthcare insurance services or third-party payors, including but not limited to Medicare, insurance, among others for which are only covered by them.
I understand that there are certain procedures and/or treatments that may not be covered or partially covered by healthcare insurance services. In this case, I understand that I shall be financially responsible and may receive a separate billing for the procedures taken.