By signing below, I hereby acknowledge, agree, and authorize all of the following:
a) Accurate Information.
I certify that the information provided on this form is accurate,
complete, and up to date to the best of my knowledge.
b) Patient Rights and Responsibilities.
I understand that the healthcare facility maintains a
Notice of Privacy Practices, which describes how my protected health information may be
used and disclosed, and how I may access my health records. I understand that I have the
right to review this healthcare facility's Notice of Privacy Practices prior to signing this form.
c) Release of Medical Information.
I authorize the release of my health information to the
healthcare facility in accordance with the healthcare facility's Notice of Privacy Practices.
This includes, but is not limited to, releasing medical information to my referring physician,
primary care physician, and any physician(s) or insurances billing purposes I may be referred
to. The healthcare facility shall ensure all health information remains confidential, as
required by HIPAA, and will not release any of my health information without my consent.
d) Consent for Treatment.
I grant the healthcare facility, including its affiliated providers,
physicians, and other medical personnel, permission to use the health information provided
for the purpose of my medical treatment as necessary.
e) Consent to Communication.
I consent to receiving communications from the healthcare
facility regarding appointment reminders, test results, and other necessary
healthcare-related information via phone, email, or channels.
f) Acknowledgment.
By signing below, I hereby acknowledge, agree, and authorize all of
the above, and I authorize the healthcare facility to retrieve and review my medical history
and authorize the healthcare facility to release the information required in obtaining
procedure authorization or the processing of any insurance claims.
g) Controlled Substances.
I understand that controlled substances of any kind will not be
prescribed by any provider at Vantage Medical Associates P.C. unless the patient is an
established patient in this office. at least 90 days. According to the provider's assessment,
they will determine whether it is medically necessary to give you prescriptions for
controlled medications, and there is no guarantee that the prescription for controlled
medications will be written I also understand that there are no considerations or
exceptions that I owe this and that if I need any special type of drug managed I will accept
the provider's decision to refer me to another medical site outside this office.
