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* MM slash DD slash YYYY 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 SignatureI 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):* MM slash DD slash YYYY Consent For Care & Payment - Digital SignatureCONSENT 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):* MM slash DD slash YYYY To submit, what is 20+20=* CommentsThis field is for validation purposes and should be left unchanged.