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.