HIPPA NOTICE/CONSENT FORM
Authorization for Treatment: The person names below (hereinafter called Patient). Consents that Narendra Kansal, MD (hereinafter called the Provider), his healthcare providers, clinical and technical employees and consulting physicians or any assistants, whom they may call to their aid, may administer any treatment deemed advisable in the care and treatment of the Patient. Patient also consents to all procedures that whether for diagnosis or treatment prior to or during the procedure may be deemed advisable in their care and treatment. Patient further understands that no guarantee of assurance has been made as to the results that may be obtained. Assignment Of Benefits: The Patient and / or insured requests that payment of any existing insurance benefit is made on their behalf to all providers of service during this encounter. The patient understands that it is necessary for Narendra Kansal, MD to release certain medical information in order to receive payment of its debt from the third party insurers or governmental providers.Terms of Financial Agreement: The patient agrees to pay all charges made by Narendra Kansal, MD or other service providers for the services rendered to the patient. Any portion of the bill not covered by insurance or other benefits is due in full at the time of services unless prior arrangements have been made. Patient understands that insurance is a contract between the subscriber and the insurance company and that Narendra Kansal, MD will bill the insurance carrier as a courtesy to the Patient. All required authorizations, pre-certifications, and/or referral forms are the responsibility of the patient.HIPPA Acknowledgement / Consent Notice Written Authorization. I acknowledge receipt of Narendra Kansal, MD, Notice of Privacy Practices. I give consent to Narendra Kansal, MD to obtain or disclose my protected health information for the purpose of treatment, payment or health care operation. I give my consent to Narendra Kansal, MD to leave messages about my appointments and/or normal test results at my home on my answering machine or with another party designated by myself. Should I choose to change my authorization I will contact Narendra Kansal, MD by writing.
By signing below, patient understands and accepts the above stated policies(s) of Narendra Kansal, MD; furthermore this acknowledgment will remain in effect until cancelled, in writing, by the patient.
TO RELEASE MEDICAL INFORMATION TO FAMILY MEMBERS/SIGNIFICANT OTHER ON YOUR BEHALF.
