J&R Medical Notice of Privacy Practices Sample Clauses

J&R Medical Notice of Privacy Practices. I have received, read and understand the J&R Medical Notice of Privacy Practices This Agreement is considered ongoing for urological, incontinence and medical supplies. The undersigned certifies that he/she has read the foregoing, received a copy thereof, and if the patient, or is duly authorized by the patient as the patient’s general agent to execute the above and accept its items. Beneficiary (or Parent/Guardian/Agent) Signature Date Relationship to Patient (if applicable) Reason Patient Unable to Sign (if applicable)

J&R Medical Notice of Privacy Practices. I have received, read and understand the J&R Medical Notice of Privacy Practices This Agreement is considered ongoing for urological, incontinence and medical supplies The undersigned certifies that he/she has read the foregoing, received a copy thereof, and if the patient, or is duly authorized by the patient as the patient’s general agent to execute the above and accept its items. Beneficiary (or Parent/Guardian/Agent) Signature Date Relationship to Patient (if applicable) Reason Patient Unable to Sign (if applicable) General Medical Records Release and Authorization for Use or Disclosure of Protected Health Information Please complete the following information: Patient Name: Address: Phone: SSN: Date of Birth: / _/ I authorize the custodian of records of: or other person/entity (specifically describe) to disclose/release the following information* (check all applicable): All records Laboratory/pathology records X-ray/radiology records Billing records Abstract/Summary Pharmacy/prescription records Other (describe specifically) These records are for services provided on the following date(s): Please send the records listed above to (use additional sheets if necessary): Name: Address: Name: Address: Phone: Phone Fax: Fax: The information may be used/disclosed for each of the following purposes: At my request (only the patient can check this box) For my health care For payment/insurance For employment purposes Other: This authorization shall expire no later than: / / or upon the following event (whichever is sooner). By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information. Signature of patient (or patient’s Date personal representative) J&R Medical ● xxx.XxxxXxxxxxxx.xxx Toll Free: 000.000.0000 ● Fax: 000-000-0000 MEDICARE DMEPOS SUPPLIER STANDARDS Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).