Privacy and Billing Procedures NextCare

These authorizations/acknowledgements cover all services rendered to me, or the patient I am signing for, today and all future dates of service. I understand I may revoke this authorization by informing NextCare in writing, but if I do revoke this authorization, it will not affect anything prior to the date the revocation is received by NextCare.

INFORMATION CHECKLIST

I have received and read the Authorization to Treat and Bill ____YES ____NO

I have received and read the Notice of Privacy Practices ____YES ____NO

I have received and read the Patient Rights and Responsibilities ____YES ____NO

I have received and read the Consent for Email and Voicemail Communication ____YES ____NO

AUTHORIZATION OF INFORMATION RELEASE I have received a copy of NextCare’s Notice of Privacy Practices. I authorize NextCare to release any information regarding my treatment; including lab results, x-rays, and medical records, to the following individuals/entities (NextCare may not release information or records to the names individuals/entities unless you identify them here):

Name _________________________________________________

Relationship to Patient ______________________

Name _________________________________________________

Relationship to Patient ______________________

Name _________________________________________________

Relationship to Patient ______________________

Name _________________________________________________

Relationship to Patient ______________________

NextCare will use my home phone number and primary address supplied during registration to contact me regarding my treatment; including lab results, x-rays, and medical records. I will ensure this information is up to date at every visit.

COMMUNICATIONS CONSENT I have received a copy of NextCare’s Consent for Communications and consent to all communication, including but not limited to lab test results, x-ray findings, medical records, future appointments, and other communication about my medical condition and advice from NextCare by the following means (check all that you consent to):

Email ____YES ____NO EmailAddress______________________________________________________________

Voicemail ____YES ____NO

Phone Number__________________________________________________________

PATIENT INFORMATION Patient Name (Printed) _______________________________________________ Date of Birth: _________________

Patient Signature: __________________________________________________________

Date: _________________

Parent Representative (Printed)*: ______________________________________________

Date*: _________________

Parent Representative Signature*:_____________________________________

Relationship*: ____________________ *

(Required if the patient is a minor or if the patient is unable to sign this form.