I authorize the release of any medical information including the diagnosis and the records of any treatment or examination rendered to me or my child/dependant during the period of such care to my primary care physician, or other referring physicians, and to consultants if needed and as necessary to process prescriptions. I authorize and request my insurance company to pay directly to the doctor or doctor's group insurance benefits otherwise payable to me.
Regarding information about my care, I give my permission for the office of My Florida Green and/or Athina Kyritsis, MD. to leave a message on my answering machine and/or voice-mail and to message me via email or electronic message, if necessary. I understand that I will have access to a patient portal where I can review information regarding my care online. If at any time I decide to revoke this form of communication, I agree to directly notify the doctor.
In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial policies of this office. Payment is required for all services at the time they are rendered. We accept payment in the form of cash or credit card. Your signature below signifies your understanding and willingness to comply with this policy.
Our Notice of Privacy Practices provides information about how we may use and disclosed protected health information about you. The notice contains a Patient Rights section describing your rights under federal and state law. You have the right to review our Notice before signing this consent. The terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to use our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The patient understands that:
Protected health information may be disclosed or used for treatment, payment, or health care operations.
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this notice.
The Practice reserves the right to change the Notice of Privacy Practices.
The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions.
The patient may revoke this consent in writing at any time and all future disclosures will then cease.
The Practice may condition receipt of treatment upon the execution of this consent.
I consent to Photographs that may need to be taken for documentation, referral and educational purposes. I understand these will not be made public.
By signing this form, I acknowledge that I understand the contents of the NOTICE OF PRIVACY POLICIES, detailing how my information may be used. I permit a copy of this authorization to be used in place of the original. I have been offered a copy of the NOTICE OF PRIVACY PRACTICES but declined to accept a copy. Should I decide to request a copy, I agree to contact Athina Kyritsis, MD. as the Safety Officer and he/she will forward me a copy of the NOTICE OF PRACTICE POLICIES.