What s the name of your position?
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- Sheila Thornton
- 5 years ago
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3 What s the name of your position? What are some basic work responsibilities (e.g primarily front desk/administration, light lifting or heavy liftingplease indicate pounds)?
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5 CONSENT FORM FOR USE AND DISCLOSURE OF HEALTH INFORMATION With my consent, Dr. Spence or his designee, may use and disclose protected health information about me to carry out treatment, payment and healthcare operations. Please refer to our Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. We reserve the right to revise the Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Practice Privacy Officer at:. Name of Privacy Officer: Practice: Address: City, State, Zip. Sharon Jones Caple Spence, M.D National Avenue, Suite 210 Midwest City, OK Telephone Please circle Yes or No With my consent, Dr. Spence or his designee may call my home or another designated location and leave a message (on voic , answering machine or in person) in reference to any items that assist the practice in carrying out treatment, payment and healthcare operations. This may included appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory and other results. 2. Mail Please circle Yes or No With my consent, Dr. Spence or his designee may mail to my home or another designated location any items that assist the practice in carrying out treatment, payment and healthcare operations such as appointment reminder cards, correspondence and billing statements. 3. Please circle Yes or No With my consent, Dr. Spence or his designee may any items that assist the practice in carrying out treatment, payment and healthcare operations, correspondence and billing statements. Please request any specific restriction(s) you may have to the use and/or disclosure of your health information: We may release your health information to other physicians, medical facilities and health insurance companies who are providing your medical care and health coverage. NOTE: If there are additional individual(s) and/or organizations(s), you must list them below or we will not be able to release any information to them. Spouse: Other family: Other: I have the right to request that Dr. Spence or his designee restrict the use or disclosure of my protected health information to carry out treatment, payment and healthcare operations. (Please request form.) I understand that the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I consent to the use and disclosure of my protected health information to carry out treatment, payment and healthcare operations by Dr. Spence or his designee. I may revoke my consent in writing to the extent that the practice has already made disclosures based upon my prior consent. If I do not sign this consent, Dr. Spence may decline to provide treatment to me. Your signature below will verify your consent of above information and that you have received a copy of our Private Policy. Signature of Patient or Legal Representative Date signed
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Maintenance for Wakefulness Testing (MWT) Dear, Your Maintenance for Wakefulness Testing (MWT) will begin on the morning of at 7 a.m. and will end at 5 p.m. ARRIVAL TIME: If you are not able to arrive
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Dear prospective patient: We thank you for choosing the, At the Navy Yard. 3 Crescent Drive, in Suite 100 (on site parking) 215-503-3300 We are happy to be involved in your care. Please complete the enclosed
More informationWhy Do I need an Annual Wellness Visit?
Why Do I need an Annual Wellness Visit? To Our Medicare Patients: Medicare covers once a year wellness exam. There is no deductible, copay or coinsurance with your wellness visit. Medicare is very specific
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