Consent for Purposes of Treatment, Payment & Healthcare Operations
In this document, “I” and “my” refer to the patient and “Chiropractor” refers to Dr. John Fitzgerald DC.
I consent to the use or disclosure of my protected health information by Chiropractor for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Chiropractor. I understand that analysis, diagnosis or treatment of me by Chiropractor may be conditioned upon my consent as evidenced by my signature below.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. If Chiropractor agrees to a restriction that I request, the restriction is binding on the Chiropractor. I have the right to revoke this consent, in writing, at any time, except to the extent that Chiropractor has taken action in reliance on this Consent.
My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I have been provided with a copy of the Notice of Privacy Practices of Chiropractor and understand that I have a right to review that Notice prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Chiropractor. It also describes my rights and the duties of the Chiropractor with respect to my protected health information.
Chiropractor reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail, or by asking for one at the time of my next appointment.
Attorney lien authorization
Required for auto accident visits — please read, check the box, and sign below.
I do hereby authorize the above provider to furnish to you, my attorney, with a full report of his case history, examination, diagnosis, treatment and prognosis of myself in regard to my injury. I hereby give a lien to said provider on any settlement as a result of my injury, and authorize and direct you, my attorney, to pay directly to Dr. John Fitzgerald such sums as may be due and owing him for services rendered to me, and to withhold such sums from such settlement as may be necessary to protect Dr. John Fitzgerald adequately.
I fully understand that I am directly and fully responsible to Dr. John Fitzgerald for all bills submitted by him for care rendered to me. This agreement is made solely for Dr. John Fitzgerald's additional protection and in consideration of his awaiting payment.
I understand that I am responsible for any and all outstanding bills relating to this office.
I would like a separate check written to Dr. John Fitzgerald for my care.