I hereby give consent for medical information to be sent to my Referring Primary Care Physician. I also request that
payment of authorized insurance benefits be made on my behalf to Erik Pasin,M.D. for any service furnished me by Dr.
Pasin, I authorize any holder of medical information about me to release such information necessary to determine
these benefits or the benefits payable to related services. I understand my signature requests that payment be made
and authorizes release of medical information necessary to pay the claim. I understand that if I am found to be
ineligible for insurance coverage, I am responsible for all costs incurred in the delivery of medical services to me
and will pay these charges within 30 days of billing. Co-payments will be collected at the time of service. I
further agree in the event of non-payment to bear the cost of collection and/or court fees. I will be responsible to
pay $25.00 for any missed appointment.
There will be a $25.00 fee on each returned check.
What is the main reason for your visit today? (Please describe in detail)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED ANO HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to
carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required
by law. It also describes you rights to access and control your protected health information. "Protected health
information" is information about you, including demographic information that may identify you and that relates
to your past, present or future physical or mental health or condition and related to health care services.
1 Uses and Disclosure of Protected Health information
Your protected health information may be used and disclosed by your physician, our office staff and others outside
of our office that are involved in your care and treatment for the purpose of providing health care services to you,
to pay your health care bills, to support the operation of the physician's practice, and any other use required by
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health
care and any related services. This includes the coordination or management of your health care with a third party.
Far example, we would disclose your protected health information, as necessary, to a home health agency that
provides care to you. Far example, your protected health information may be provided to a physician to whom you have
been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services.
For example, obtaining approval for a hospital stay may require that your relevant protected health information be
disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as -needed, your protected health information in order to support the
business activities of your physician's practice. These activities include, but are not limited to quality
assessment activities, employee review activities, training of medical! students, licensing, and conducting or
arranging for other business activities. For example, we may disclose your protected health information to medical
school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk
where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting
room when your physician is ready to see you. We may use or disclose your protected health information, as
necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization.
These situations include: as Required By Law, Public Health issues as required by law, Communicable diseases: Health
Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings, Law Enforcement:
Coroners, Funeral Di9rectors, and Organ donation: Research: Criminal Activity: Military Activity and National
Security: Workers' Compensation: Inmates: Required Uses and disclosures: Under the Law, we must make disclosure to
you and when required by the Secretary of the Department of Health and Human Services to investigate or determine
our compliance with the requirements of Section 164.500.
Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity
to object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the
physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Following is a statement of you rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may
not inspector copy the following records; psychotherapy notes; information compiled in reasonable anticipation of,
or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is
subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means ... you may ask
us not to use or disclose any part of your protected health information for the purposes of treatment, payment or
healthcare operations. You may also request that any part of your protected health information not be disclosed to
family members or friends who may be involved in your care or for notification purposes as described in this Notice
of Privacy Practices. Your request must state the specific restriction requested and to whom you want the
restriction to apply.
Your physician is not required to agree to a restriction that you may request. if physician believes it is in your
best interest to permit use and disclosure of your protected health information, you protected health information
will not be restricted. You then have the right to use another Healthcare Professional.
You may have the right to request to receive confidential communications from us be alternative means or an
alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even
if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to have your physician amend your protected health information. If we deny your
request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal
to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have
the right to object or withdraw as provided in this notice.
You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been
violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not
retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before April 14, 2003.
We are required by law to maintain the privacy of and provide individuals with, this notice of our legal duties and
privacy practices with respect to protected health information. If you have any objections to this form, please ask
to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.
Signature below is only acknowledgment that you have received this Notice of our Privacy Practices: