HIPAA Notice of Privacy Practices

My signature on this document acknowledges that I have received Quick Primary Care, PA HIPAA Notice of Privacy Practices.

LIFETIME AUTHORIZATION

Insurance Assignments and Authorization to Release Information

RELEASE OF INFORMATION- I, the below named patient, do hereby authorize any physician examining and /or treating me to release to any third payer (such as an insurance company or governmental agencies, e.g. Blue Cross Blue Shield of Florida or Medicare) any medical, psychiatric conditions, alcohol/drug related condition and records concerning diagnosis and treatments when requested by such third party for its use in connection with determining a claim for payment for such treatment and /or diagnosis.

PHYSICIAN INSURANCE ASSIGNMENT- I, the below named subscriber, hereby authorize payment directly to any physician examining or treating me or any group and/or individual surgical and/or medical benefits herein specified and otherwise payable to me for their services as described but not to exceed the reasonable and customary charges for these services.

MEDICARE/MEDICAID- Patient's certification authorization to release information and payment request. I certify that the information given by me in applying for payment under Title XVIIXIX of the Social Security Administration division of Family Services or its intermediaries or carriers any information needed for this or a related Medicare/Medicaid claim. I hereby certify all insurance pertaining to treatment shall be assigned to the physician treating me.

CONSENT FOR TREATMENT- I, the below named patient hereby give my consent for treatment to all physicians associated with Quick Primary Care, PA

PERMIT A COPY OF THIS AUTHORIZATION AND ASSIGNMENTS TO BE USED IN PLACE OF THE ORIGINAL WHICH IS ON FILE AT THE PHYSICIAN'S OFFICE.

The assignment will remain in effect until revoked by me in writing.

CONSENT TO DISCUSS MEDICAL CONTINTIONS OR RELEASE RECORDS: I, the below named patient, do hereby authorized Quick Primary Care, PA to discuss my medical conditions with, or release my medical records to the below named person (s):