I authorize Premier Medical Associates to release to any insurance company/Medicare or its carriers any information needed to process and pay my claims. I permit a copy of this to be used for that purpose and to request payment of medical insurance and medical benefits to be made directly to Premier Medical Associates. I understand that it is mandatory to inform the healthcare provider of any other party who may be responsible for paying any deductible amount, co pay, or any percentage fees not paid by the insurance company of third party within a reasonable time which is not to exceed 60 days. I also authorize payment of my insurance/ Medicare benefits to be paid directly to Premier Medical Associates for my treatment. I also understand that it is my responsibility to pay any unpaid amounts not paid by the insurance company/Medicare.
Insurance regulations suggest that we inform you in advance of we believe a service may not be covered or fully reimbursed by your insurance. In the doctors professional judgment certain services are needed in order to give high quality healthcare and to help provide a diagnosis, but some services may not be reimbursed by them. These services may include but are not limited to an EKG, lipid profile, protime, biopsy, etc. We will only perform these services when required and the results will help us to provide you with optimum care. Patient Agreement: I certify that I have read and fully understand the above information. I understand that I will be responsible for payment of any medically necessary services should they be denied by my insurance.
I understand that I have the right to accept and refuse medical treatment and to exercise my right and implement an Advance Directive. An Advance Directive refers to any legal document that informs family members and medical personnel how you wish to be treated if you are hospitalized and cannot communicate your wishes. Please check the following statements that apply: Our office requires a copy of such documents.
This release will remain effective until terminated by me in writing. In addition, messages regarding my healthcare can :
By signing this form, I authorize the release my confidential health information.
The information to be release is as follows:
By signing this form, I authorize the release of my confidential health information including sensitive information such as: Drug/ Alcohol abuse, Psychiatric, Venereal Disease, Social Service, Hepatitis B Testing/ Treatment, HIV (AIDS) Testing/ Treatment, and other sensitive information.
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Premier Medical
Associates for as long as I continue to receive services from them. If were to receive any checks (payments) intended as payment for
services rendered by Premier Medical Associates from Medicare or other insurance company(ies), will immediately endorse them and
turn over to Premier Medical Associates for service rendered. Understand that I am financially responsible for any balance. Also,
authorize Premier Medical Associates or insurance company to release any information required to process my claims.
I authorize any holder of medical or other information about me to release to the social security administration or its intermediaries or
carriers any information needed for this or a related Medicare or other insurance company claim. Permit a copy of this authorization to
be used in place of the original, and request payment of medical insurance benefits either to me or to the party that accepts
assignment. I understand that it is mandatory to notify the healthcare provider of any other party that may be responsible for paying
for my treatment (Section 1128B of the social security act and 31 U.S.C. 38/01-3812 provides penalties for withholding this
Insurance regulations suggest that we inform you in advance if we believe a service may not be covered or fully reimbursed by your
insurance. In the doctors professional judgement certain services are needed in order to provide high quality healthcar and to help
provide a diagnosis, but some services may not be reimbursed by them. These services may include but are not limited to EKG, lipid
profile, protime, biopsy, etc. We will only perform these services when required and the results will help us provide you with optimum
Patient Agreement: I certify that I have read and fully understand that I will be responsible for payment of any medically necessary
services should they be denied by my insurance.
Florida law requires that your healthcare provider or healthcare facility recognize your rights while
you are receiving medical care and that you respect the healthcare provider’s or healthcare facility’s
right to expect certain behavior on the part of patients. You may request a copy of the full text of this
law from your healthcare provider or healthcare facility.
It is our obligation as a healthcare facility to inform you that you have the right to contact these tollfree
numbers to report if you have any complains, abuse, neglect or exploitative practices.
Complaints: To report a complaint regarding the services you receive please call toll-free 1-888-419-
3456 or visit ahca.myflorida.com/contact/call_center.shtml.Abuse, neglect or exploitative practices:
To report abuse, neglect or exploitation, please call toll-free 1-800-96-ABUSE (962-2873)
Florida State Law guarantees that I have both the right and obligation to make decisions
concerning my health care. Your physician can provide you with the necessary information and
advice, but as a member of the health team, you must enter into the decision process. This
form has been designed to acknowledge your acceptance of treatment as recommended by
Further acknowledge that I will have full opportunity to discuss this information with my
physician and hereby consent to medical care/treatment and the release of pharmacy history.
Also, acknowledge that the purpose of care, reasonable alternative forms of therapy; risks of
the recommended and alternative care and the risks of foregoing care will be explained to me.
I hereby consent and authorize my physician and any of the health professionals as designated
to perform examination and routine diagnostic procedures upon me. I also consent to and
authorize my physician to prescribe a therapeutic regime, which I shall follow. Unless explicitly
refuse, I consent that the diagnostic test (s), treatment (s), procedure (s), contraceptive
method (s) and immunizations ordered by my physician be performed on me despite the risks
involved and complications that might be involved, which will be explained to me at the time
they are ordered. I understand that must tell the staff if language interpreter services are
necessary for my understanding of the written and spoken information during my health care
visits. I also, understand that interpretive services may not be immediately available. No
guarantee has been given to me about the results of any of the services that I receive. I
understand that if tests for certain sexually transmitted and other diseases are positive, report
of positive results to public health agencies is required by law will be given referrals for further
diagnoses and treatment if necessary.
CONSENT TO TREAT: I consent to medical care and treatment as may be deemed necessary or
advisable in the judgment of my physician, which may include but are not limited to; laboratory
procedures medical or surgical treatment or procedures, local anesthesia, or other services
rendered the patient under the general and special instructions of the patient’s physician.
It tells me how Premier Medical Associates will use my health information for the purpose of
my treatment, payment for my treatment, and Premier Medical Associate’s health care
The Notice explains in more detail how Premier Medical Associates may use and share my
health information for other than treatment, payment, and health care operations.
Premier Medical Associates will also use and share my health information as
required/permitted by law.
If I am a patient of Premier Medical Associates receiving health services, I consent to Premier
Medical Associates using and disclosing my treatment and education records maintained by
Premier Medical Associates for the purposes detailed in the Premier Medical Associates Notice
of Privacy Practices.
I acknowledge that have been provided the
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I hereby give my consent for Premier Medical Associates to use and disclose
protected health information (PHI) about me to carry out treatment, payment and
health care operations (TPO). (The Notice of Privacy Practices provided by Premier
Medical Associates describes such uses and disclosures more completely.)
I have the right to review the Notice of Privacy Practices prior to signing this
consent. Premier Medical Associates, reserves the right to revise its Notice of Privacy
Practices at any time. A revised Notice of Privacy Practices may be obtained by
forwarding a written request to Premier Medical Associates.
I have the right to request that Premier Medical Associates restrict how it uses or
discloses my PHI to carry out TPO. The practice is not required to agree to my requested
restrictions, but if it does, it is bound by this agreement.
With this consent, Premier Medical Associates may call my home or other
alternative location and leave a message on voice mail or in person in reference to any
items that assist the practice in carrying out TOP, such as appointment reminders,
insurance items and any calls pertaining to my clinical care, including laboratory test
results, among others.
With this consent, Premier Medical Associates may mail to my home or other
alternative location any items that assist the practice in carrying out TPO, such as
appointment reminder cards and patient statements as long as they are marked
“Personal and Confidential.”
With this consent, Premier Medical Associates may e-mail to my home or other
alternative location any items that assist the practice in carrying out TPO, such as
appointment reminder cards and patient statements.
By signing this form, I am consenting to allow Premier Medical Associates to use
and disclose my Personal Health Information to carry out TPO. I may revoke my consent in
writing except to the extent that the practice has already made disclosures in reliance upon
my prior consent. If I do not sign this consent, or later revoke it, PMA may decline to
provide treatment to me
The following person(s) may contact Premier Medical Associates inquiring in
regards to my health information. You have my permission to release information to them.
I may revoke my consent in writing except to the extent that the practice has already made
disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it,
Premier Medical Associates may decline to provide treatment to me. In a addition, messages
regarding my healthcareCAN(initial)CAN NOT(initial) be left on message
machines using the telephone numbers I have provided.
What are Advanced Directives? Advanced Directives is a general term that refers to your oral or
written instructions about your future medical care in the event you are unable to speak or make decisions
What is a Living Will? A Living Will is a form of advance directive in which you put in writing your
wishes about medical treatment at the event you become unable to communicate your wishes.
What is a Medical Power of Attorney? A Medical Power of Attorney is a document that lets you
appoint someone you must to make decisions about your medical care if are unable to those decisions for
Why do I need an Advanced Directive? Advance Directives you a voice in decisions about the medical
care you receive when you are unconscious or too ill to communicate. As long as you are able to
communicate your own decisions your advanced directives will not be used and you can accept or refuse
any medical treatment. But if you become seriously ill, you may lose the ability to participate in decisions
about your own treatment.
What happens if I do not have an Advance Directive? In the event that you cannot speak and make
decisions for yourself, someone not of your choice or may make health and medical decisions by the
Once I make an Advance Directive, can I cancel it? Yes, your advance directive can be canceled or
revoked in writing by you at any time.
Who should I talk about Advanced Directives?
Your Primary Care is the best person to answer any additional questions you might have. Your doctor has
the knowledge and cares about you to put your concerns at ease. All the necessary paperwork and
information is available at your Primary Care.
Above listed patient authorizes the following healthcare facility to make record disclosure:
Dates and Type of information to disclose:
RESTRICTIONS: Only medical records originated through this healthcare facility will be copied unless otherwise
requested. This authorization is valid only for the release of medical information dated prior to and including the date
on this authorization unless other dates are specified.
I understand the information in my health record 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.
This information may be disclosed and used by the following individual or organization:
I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing
and present my written revocation to the health information management department. I understand that the revocation will not
apply to information that has already been released in response to this authorization. I understand that the revocation will not
apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless
otherwise revoked, this authorization will expire on the following date, event, or condition:-
If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed. 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 obtain a copy of 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 the authorized individual or organization making disclosure. I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am
familiar with and fully understand the terms and conditions of this authorization.
(Guardian or Authorized Representative must attach documentation of such status.)