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Frisco on Legacy Dr.
Frisco on Eldorado
North Richland Hills
Are you an existing patient
Acknowledgement of Notice of Privacy and HIPPAA Notice of Privacy Practice
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of care and services at this practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this practice, whether made by practice personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic. If selected yes above, I authorize release of medical information to the authorized emergency contact. By signing this document, I acknowledge that I have read and understand the Notice of Privacy Practices and the HIPAA Privacy Act practices. If you have any questions about this notice, please contact the Privacy Officer/Office Manager. Due to patient privacy laws no photography or electronic recordings is permitted in the clinical area.
Release of Medical Information and Authorization for Treatment
I authorize the release of any medical information to process a claim and further authorize payment of insurance benefits directly to Legacy ER or its affiliates. To provide for a continuity of care, I authorize the release of medical information to physicians who are participating in my care. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize Legacy ER and or its affiliates to perform procedures and treatment including the administration of medical and local anesthetics along with other surgical and medical procedures that may be necessary. I hereby grant permission to Legacy ER and or its affiliates to release any pertinent information to my insurance company upon request, and I also authorize payments to be made on my behalf directly to Legacy ER and or its affiliates. A photocopy of this authorization shall be considered as effective and valid as original.
Acknowledgement of Receipt of Financial Policy
I acknowledge that I have received the financial policy and the assignment of benefits and rights to pursue ERISA. I understand the policies and agree to abide by their guidelines. In addition, I acknowledge receipt of the HIPAA notice, release of Medical Information and agree to consent of treatment as listed above.