HIPPA Compliance

Date:

Patient's Name:

Patient's Email Address:

Patient's Date of Birth:

Authorization and Consent for Health Care

I hereby authorize the physicians of Aurora Gonzalez MD, PA to release any information acquired in the course of my treatment to my insurance company, employer, or third party payor as required for claims filed, quality assurance, health plan administration, or complaints/grievances. I understand that the specific information to be released may include, but is not limited to history diagnosis and/or treatment of all related illness including HIV virus and Acquired Immune Deficiency Syndrome (AIDS).

I authorize direct payment to be made to the physicians at Aurora Gonzalez MD, PA or other providers for any and all medical or surgical services rendered. I understand that if any services or charges are not covered, or if Aurora Gonzalez MD, PA is not able to verify eligibility, that I am responsible for all charges incurred for services rendered.

I hereby voluntarily consent to such healthcare encompassing diagnostic procedures and treatment by my physicians, and my physician’s associates, assistants, and other healthcare providers, as may be necessary in my physician’s judgment. I have relied on my physicians for information in this regard and acknowledge that no warrantee or guarantee has been made to me as to result or cure. This form has been fully explained to me, and I certify that I understand its contents.

Acknowledgement of Review of Notice of Privacy Practices

I have reviewed this office’s Notice of Privacy Practices and authorization and consent for health care, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

Consent for Communication of Protected Health Information

I, give my consent to Aurora Gonzalez MD, PA to release Protected Health Information to the people or facilities listed below. This is to include any lab, diagnostic or therapeutic testing, including HIV testing, or any medical condition.

Name:Relationship:

Or, Initial, for release of records to NO ONE.Initials: