Carlos A Lozano MD PA

Available Forms

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES Additional Insurance Information Form Appointment Request Authorization to Release Medical Information New Patient Information Form Notice of Privacy Practices Prescription Refill Request Request of Medical Records

Authorization to Release Medical Information

Authorization to Release Medical Information to Individuals/Family Members

In accordance with Federal government privacy rules implemented through the Healthcare Portability and Accountability Act of 1996 (HIPAA), in order for your physician or staff of the Practice to discuss your conditionwith members of your family or other individuals that you designate, we must obtain your authorization prior lo doing so. In the event of a critical episode or if you are unable to give your authorization due to the severity of your medical condition, the law stipulates that these rules may be waived. The Practice has posted the Patient's Rights and Patient Responsibilities in the waiting room. A copy of these Rights and Responsibilities will be provided If so requested.

Authorization

I DO NOT AUTHORIZE

I AUTHORIZE

the Practice to release any or all information concerning my medical condition to any individuals or organizations not involved in Treatment, Payment or Healthcare Operations as related to care or services provided by CARLOS A. LOZANO, M.D.

Name & Relationship to patient

Pt or Legally Responsible Party Initials

By initialing, you agree to the statement below.

Date

* Required field