Epstein Secrets

l medical records, physically or verbatly, concerning my care to the following specified parties: Referring Physician Insurance Company, Medicare, Medicaid, Third Party Administrator, Managed Care Company Consent Required Consent Required Additional Party Name Relationship to Patient 2. 3. 4. Au

rmation to Individualffamily Members In accordance with Federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPAA), in order for your physician or staff of the Practice to discuss your condition with members of your family or other individuals that you designate

hysically or verbally, concaving ay tare to the following specified parties: Referring Physician D 0i.1r.lfle KRue€R. Insuranco Company, Medicare, Medicaid, Third Party Administrator, Managed Care Company Additional Party Name Consent Required Consent Required Relationship to Patient 4. S. Author

ation to Individualfamily Members in accordance with federal government privacy rules anptitmer tad through the Healthcare Portability Act of 1906 (HIPAA). in order for your physician or staff of the Practice to discuss your condition with members of your family or other individuals that you des-gnatb

Association. My activities within the Association are a private matter that I refuse to share with the State Medical Board, the FDA, FTC, Medicare, Medicaid or my own insurance company without my expressed specific permission. All records and documents remain as property of the Association, even if I rec

f membership records maintained within the Association which have been held to be inviolate by the U.S. Supreme Court, the undersigned member waives HIPAA privacy rights and complaint process. Any medical or healthcare records kept by the association will be strictly protected and only released upon w

have any life insurance or death benefits skip to 14 ) Company Name Address Phone I Life Insurance _ Pension Plan — Other InsuranceiPlan — Medicaid Workers Compensation If any other insurance or death benefits. list here: Do any of these policies Cover the =Ws burial expenses' Has anyone app

ION PURSUANT TO HIP In accordance with New York State Law and the Privacy Rule of the I lealth Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, exce

ofarson's, myerefl by this incritiner Pnmary Insurance Company Major Medical Insurance Company Other Insurance (Union, Deed& Vision at) Medicare Medicaid Workers' Compensation Auto Insurance Other insurance Rev September 2016 I . ._ct-c- LLD gess, 1/4.,e_ Pigs 3 of 4 EFTA01650840 •HIPAA• OC

-c- LLD gess, 1/4.,e_ Pigs 3 of 4 EFTA01650840 •HIPAA• OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health' Patient Name Date of Binh I or my authorized representative, request tha

on(s) covered by Ibis insurance. Primary Insurance Company Major Medical Insurance Company Other Insurance (Union. Dental. Vision. etc.) Medicare Medicaid Workers' Compensation Auto Insurance Other insurance Rev September 2015 Page 3 ol EFTA01650947 13 If the victim died, tell us about any life

s. (Keep a copy for your records.) • All bills and receipts for sennces listed on this form • Your completed, signed claim form • One completed HIPAA farm for each service provider listed on this form (You can photocopy the HIPAA form ) • Letters from any insurers denying or authorizing payment f

me of s covered by this insurance: Primary Insurance Company Major Medical Insurance Company Other Insurance (Union, Dental, Mims etc) Medicare Medicaid Workers' Compensation Auto Insurance Other insurance Rev September 2015 Page 3 of 4 EFTA01651060 13 If the victim died, tell us about any lif

Ot:A Official Form No.: 960 H1PAA• AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health' I, or my authorized representative, request that h h information regardin

ar Olth.el €.41 I -1 .39-49/ Declining coverage due to existence of other coverage: Spouse's Employers Plan Individual Plan Covered by Medicare Medicaid COBRA from Prior Employer VA Eligibility Tn-Care I (we) have no other coverage at this time Other I understand that by waiving coverage at thi

nitedHealthcare representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA. UnitedHealthcare also requires that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain

Existing Pa ent? nes r - No Declining coverage due to existence of other coverage. Spouse's Employer's Plan Individual Plan Covered by Medicare Medicaid COBRA from Pnor Employer VA Eligibility Tn-Care I (we) have no other coverage at this lime Other I understand that by waiving coverage at this

UnitedHealthcare representative in wnting, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA. UnitedHealthcare also requires that I acknowledge the following, which I do. I understand that information I authorize a person or entity to obtain