If yes, please provide copy of your medical device card to front desk.
As the patient you acknowledge with the completion of this form it constitutes your complete clinical history summary
By entering my name I agree that the signature and initials will be the electronic representation of my signature and initials for all purposes when I
use them in this form - just the same as a pen-and-paper signature or initial
All professional services rendered are charged to the patient and are due at the time of service, Unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file insurance carrier payments.
I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical plan, to issue payment check(s) directly to Advocate Radiation Oncology LLC medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.
I hereby authorize Advocate Radiation Oncology LLC to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow photocopy of my signature to be used to process insurance claims for the period of lifetime. This order will remain in effect until revoked by me in writing. I have requested medical services from Advocate Radiation Oncology LLC on behalf of myself and/or my dependents, and understand that making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized. I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.
We understand that health information about you is personal and we are committed to protecting your information. We create a record of the care and services you receive at Advocate Radiation Oncology. We need this record to provide care (treatment), for payment of care provided, for health care operations, and to comply with certain legal requirements. This Notice will tell you about the ways in which we may use and disclose health information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of health information. We are required by law to follow the terms of this Notice that is currently in effect. The Health Insurance Portability & Accountability Act of 1996 S160.103, also known as HIPAA, defines individual personal health information (PHI) as information, including demographic information collected from an individual and to include information that is:
The PHI can only be disclosed through a permitted disclosure (S164.502) and used by a health care provider in the following manners:
2. Uses or disclosure to a personal representative assigned by patient.
3. Disclosure to the parents or persons acting in loco to parents to unemancipated minor.
4. For case management, care coordination for the individual, to direct or recommend alternative treatments or therapies, health care providers or health care selling.
I am a patient of Advocate Radiation Oncology LLC and understand that I am required to inform the facility of the persons to whom they may disclose my medical information. These assigned persons may be changed at any time by myself. This disclosure becomes effective the date it is signed and will continue until it is cancelled, changed, altered or amended by myself or my appointed legal representative. This facility has notified me that they have a listing of all the persons and agencies or payers to whom my medical information may be disclosed during the course of any medical treatment by this facility. I HAVE READ THE PERMITTED DISCLOSURE FORM AND I UNDERSTAND IT. I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.
I understand that uses and disclosures already made based upon my original permission cannot be taken back.
I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.
I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.
I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.
1. I authorize the use or disclosure of the above-named individual’s health information as described below:
2. The following individual or organization is authorized to make the disclosure:
4. I understand that the information in my health records may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.
5. This information may be disclosed to and used by the following individual or organization.
7. If I fail to specify an expiration date, event or condition, this authorization will expire in one year. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact a clinic representative at any of the Advocate Radiation Oncology locations.
Fort Myers Office
15681 New Hampshire Court
Fort Myers, FL 33908
Port Charlotte Office
3080 Harbor Blvd.
Port Charlotte, FL 33952
Cape Coral Office
909 Del Prado Blvd.
Cape Coral, FL 33990