Patient Consent & HIPAA Form

Click here to download a PDF of our Patient Consent & HIPAA Form or fill out the online form below.

"*" indicates required fields

Patient Name*

First Last

Date of Birth*

AUTHORIZATION FOR FAMILY/OTHERS REGARDING MY CARE:

I authorize Fox Valley Pulmonary Medicine (FVPM), to communicate with the following person(s) regarding appointments, diagnosis, care, treatment, procedures, results and billing questions related to my care:

Name 1:

First Last

Phone 1:

Relationship 1:

Name 2:

First Last

Phone 2:

Relationship 2:

Name 3:

First Last

Phone 3:

Relationship 3:

If I am unavailable, I authorize FVPM to leave messages regarding medical matters at these phone numbers:

Phone (Leave Messages 1):

Phone(Leave Messages 2):

Medical Records Release - Digital Signature

I understand that the release of copies of my medical records requires a specific authorization form signed by myself or my legal representative. This form shall remain in effect until changed or revoked by me in writing.

Signature for Medical Records Release*

Please Type Your Name (Medical Records Release):*

Date (Medical Records Rlease):*

Consent For Care & Payment - Digital Signature

CONSENT FOR CARE: I understand that by signing this document, I consent to all general outpatient medical care and/or routine outpatient services, including evaluation, therapies, nursing care and diagnostic testing provided under the general or specific instruction of my physician(s) and other health care providers.

SIGNATURE FOR PAYMENT: I request that payment of authorized insurance benefits be made to Fox Valley Pulmonary Medicine for services provided to me. I give permission to FVPM to release medical information regarding my care to insurance companies for the purpose of deciding benefits and processing claims. I agree to be responsible for charges not covered by insurance.

I understand it is my responsibility to provide FVPM with accurate insurance information. It is also my responsibility to obtain any required referrals or pre-authorizations required by my insurance company. Copayments are required by some insurance carriers and are to be made at the time of service. I agree to pay for services provided to me or my family member.

I acknowledge that there is a Notice of Privacy Practices available for me to read and receive copy of upon request.

Signature for Care Consent & Payment*

Please Type Your Name (Care Consent & Payment):*

Relationship (Care Consent & Payment):

Date (Care Consent & Payment):*

To submit, what is 20+20=*

Name

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