Dedicated to a Higher Quality of Life

Serving Southern Indiana and Louisville Metro Area

 
 
 
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"PLEASE GIVE CARDS TO RECEPTIONIST TO COPY"
CONSENT FOR TREATMENT:

I voluntarily consent to the rendering of care, including treatment and performance of diagnostic procedures, I under stand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the instructions of such physicians.

CONSENT TO OBTAIN PRESCRIPTION HISTORY:

I give my till consent for to obtain any and all records pertaining to ray prescription history.

RELEASE OF INFORMATIONIIIIPPA NOTICE OF PRIVACY PRACTICES

By Signing this form, you are granting consent to KDK to use and disclose your protected health information for the purposes of treatment, payment and health care operations. Our Notice of Privacy Practices provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review our Notice of Privacy Practices before you sign this consent, and we encourage you to read it in Mi. Our Notice of Privacy Practices is subject cc change. If we change our notice, you may obtain a copy of the revised notice by telephoning our office at ',ell: 253-9111. . You have a right to request us to restrict how we use and disclose your protected health information for the purposes of treatment, payment or health care operations. We are not required by law to grant your request. However, if we do decide to grant your recluest; we are bound by our agreement. You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your protected health information in reliance on your consent.

MEDICARE AND MEDICAID CONSENT TO RELEASE INFORMATION:

I certify that the information given by me in applying for payment under Title XVIII ana'or Title XI of the Social Security Act is correct. I authorize any holder of medical or other information about me., to release to the Social Secut-ity Administration or its intermediary carriers, any information needed for this or related Medicare or Medicaid claim.