HIPAA Authorization - CarlinVision

Due to the HIPAA Compliance Privacy Laws of the Federal Government, it is mandatory that we ask you to review and answer the questions listed below.

Name*

First Last

Date of Birth*

Contact by Telephone

May we leave message/detailed medical information on voicemail at either of these phone numbers?

Home Phone*

Yes
No

Home Phone Number*

Cell Phone*

Yes
No

Cell Phone Number*

Contact at Work

May we contact you at your place of employment?*

Yes
No

Work Phone*

Extension

May we leave a message?*

Yes
No

Authorized Persons

Do you have a particular person or family member(s) that you authorize to receive or discuss information regarding your personal health information (general information, surgical and billing)?*

Yes
No

Authorized to Receive Information*

Click the '+' sign to add additional rows. (max. = 3)

Name	Relationship	Phone

Acknowledgements

Authorization*

I hereby authorize CarlinVision to obtain or release any and all pertinent information regarding my medical care, as needed, to assist in my ongoing treatment to or from other health care providers, laboratories, radiology facilities or other institutions. The authorization remains in effect until revoked.

Yes

Consent*

I have reviewed the aforementioned information and provide my consent regarding any and all the issues as stated above.

Yes

Privacy Policy*

I have reviewed the Notice of Privacy Policy. A copy of this policy will be provided to me upon request.

Yes

Upon submission, this `Authorization to Receive/Release Information` will be awaiting your signature when you arrive for your appointment.

Email

If you would like a copy of your submission sent to you by email, enter your address here.

We will have this completed form ready for you when you check in but, to be safe, you can print, sign and bring your copy with you.