RELEASE OF MEDICAL RECORD INFORMATION. I hereby authorize Gladstone Psychiatry & Wellness, LLC to disclose all or any part of the contents of the registered patient associated with this form’s medical record to such insurance companies, organizations, or agencies that may be concerned with the payment of medical services rendered to the registered patient consistent with Federal HIPAA regulations. This authorization is given with full knowledge and understanding that such disclosure may contain information which may result in a valid denial of insurance benefits or otherwise may not serve my interests. Please review the document Consent to Xxxx and Release Medical Information to Insurance Company on page 7 of this document for further details.
Appears in 2 contracts
Samples: Patient Care and Financial Responsibility Agreement, Patient Care and Financial Responsibility Agreement
RELEASE OF MEDICAL RECORD INFORMATION. I hereby authorize Gladstone Psychiatry & Wellness, LLC to disclose all or any part of the contents of the registered patient associated with this form’s medical record to such insurance companies, organizations, or agencies that may be concerned with the payment of medical services rendered to the registered patient consistent with Federal HIPAA regulations. This authorization is given with full knowledge and understanding that such disclosure may contain information which may result in a valid denial of insurance benefits or which otherwise may not serve my interests. Please review the document Consent to Xxxx and Release Medical Information to Insurance Company on page 7 of this document for further details.
Appears in 2 contracts
Samples: Patient Care and Financial Responsibility Agreement, Patient Care and Financial Responsibility Agreement
