If I cannot speak for myself, I would like my doctor to talk about my health care and medical problems to the following person(s):

Consent to Treatment: The patient and/or authorized representative do hereby consent to any and all medical treatment which may deem advisable by the physician(s) of Gastroenterology of Greater Orlando.

Authorization for Release of Confidential Information: I hereby authorize Gastroenterology of Great Orlando to release medical information contained in my/the patient’s records to any insurance carrier, employer or other third party intermediary utilized by the patients for the purpose of obtaining information and/or reviewing the record of medical care eived by the patient for the payment of all medical charges. Copies of records may also be sent to referring physicians for continuity of care. Medical Records released may include any diagnostic or therapeutic information of visits and/or procedures performed in office.

According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA):
The patient’s medical record may not be furnished to and the medical condition of the patient may not be discussed with any other person than the patient, the patient’s legal representative, or other health care practitioners involved in the care and treatment of the patient without the patient’s written authorization. The patient may at this time authorize an individual to be actively involved in the patient’s information as mention above.

Assignment of Insurance Benefits: I assign payment directly to Gastroenterology of Greater Orlando, the insurance benefits otherwise payable to me. I understand that I am financially responsible for charges not paid by this assignment, I will assist in the collection of my insurance should there be any delay in payment. I agree to actively pursue collecting insurance payment for any claims unpaid after (30) days. In after forty-five (45) days, the claim remains unpaid, I understand the balance will be due from me.

Medicare Patients: I certify that the information given by me in applying the payment under title xvii of the Social Act is correct. I authorize Gastroenterology of Greater Orlando to release to the Health Care Financing Administration or its carriers or intermediaries any information needed for this or related Medicare claim. I hereby authorize payment directly to Gastroenterology of Greater Orlando for medical benefits otherwise payable to me as a beneficiary of the Medical Program and such other payments as may be due by other third-party payers. I agree to execute such documents as may be necessary to apply for and obtain payment. I understand that such services as, but not limited to, routine testing may not be covered by Medicare unless the physician provides medical necessity.

Pre-Authorization: Your insurance company may require pre-authorization for office visits and/or procedures. I understand that if proper authorization is not obtained from my PCP (Primary Care Physician) I will be liable for charges incurred.

Patient/Guarantor Agreement: I understand that Gastroenterology of Greater Orlando is not the business of extending credit. Therefore, it is the policy of Gastroenterology of Greater Orlando to require payment in full at the time of service. If unable to pay patient due balance in full at the time of service, I agree to make prior arrangements with the billing department.

I understand that I am financially responsible for my/the patient’s account with Gastroenterology of Greater Orlando, regardless of my insurance benefits. I authorize a copy of this form to be valid as the original.