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Dr. Tudor Scridon, MD, FACC

1300, 36th St. Unit D, Vero Beach

FL 32960

13230 US-1, Sebastian

FL 32958

Phone: 772-226-7380,Fax: 772-212-0205

Authorization For Release of Health Information

DATE:

Patient Name

Date Of Birth

Social Security Number
Format: 123-45-6789

Home Phone Number
Format: 123-456-7890

Cell Phone Number
Format: 123-456-7890

Send records via P2P including demographics, office visits, cath report, echo reports, stress test, ekgs, labs, any other imaging testing, hospital records

I hereby authorize that Dr. Tudor Scridon, MD, FACC to

Release / Obtain:
Release
Obtain

the protected health information regarding the above named person to / from:

Person/Institution

Address

Phone
Format: 123-456-7890

Fax
Format: 123-456-7890

I acknowledge and hereby consent to such that the released information may contain sexually transmitted diseases, alcohol and drug abuse, psychiatric or mental health services, HIV testing, HIV results or AIDS information.

Initials

I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written authorization unless otherwise provided for in the regulations. I may refuse to sign this authorization and that it is strictly voluntary.

If I do not sign this form, my health care and the payment for my health care will not be affected unless stated otherwise.

I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation or when the law provides for my insurer to have the right to contest a claim under my policy. Further details can be found in the Notice of Privacy Practices.

If the requestor or receiver is not a health plan or health care provider, the released information may no longer be protected by fed era l privacy regulations and may be redisclosed.

I may see and obtain a copy of the information described on this form for a copy fee if I ask for it. I get a copy of this form after I sign it if requested.

Patient/Guardian/Patient Representative

Relationship to Patient

Patient profile

Patient Name

Date Of Birth

Sex:
Male Female

Marital Status:
Single
Married
Divorced
Widowed

Street Address

City

State

Zip

Secondary Address

Home Phone Number
Format: 123-456-7890
Work Phone Number
Format: 123-456-7890
Cell Phone Number
Format: 123-456-7890
Social Security Number
Format: 123-45-6789
Email

If you do not wish to give email circle the reason:
I do not want to be web enable
I do not want to share my email

Employment Status

Employer's Name

Ethnicity:
American Indian or Alaskan Native
White
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
Hispanic
Other Race
Other Pacific Islander
Unreported/Refused to Report

Preferred Pharmacy Location

Primary Care Physician

Have you had flu vaccine
Yes
No
If yes, Date:

Have you had pneumonia vaccine
Yes
No
If yes, Date:

Do you have advanced Directives:
No
Yes
DNR
Living Will
Medical Power of Attourney

Emergency Contact Name

Relationship

Emergency Contact
Format: 123-45-6789

MEDICARE QUESTIONNAIRE AND PRIVATE PRACTICE DISCLOSURE

Medicare Secondary Payer(MSP) regulations require the practice to gather the following information to determine if Medicare is your primary insurance.

1. Is the illness covered by the Black Lung Program or Veterans Administration?
Yes
No

2. Is the illness/injury due to an automobile accident, liability accident, or Workers' Compensation?
Yes
No

3. If under 65, are you a renal dialysis patient in your first 30 months of Medicare Entitlement?
Yes
No

4. If under 65, is your Medicare coverage due to disability?
Yes
No

5. Is patient coverage by a large group health plan through patient's employer or Spouse's current employer?
Yes
No

6. If 65 and over is patient covered by Employer Group Health Plan through patient's or Spouse's employer?
Yes
No

Patient or Legal Caregiver Name

Date:

PAYMENT POLICIES

Please read the following payment policies

Please bring all pertinent insurance information and your insurance cards with you on each visit to our office. Also, we recommend that you bring your preferred method of payment (credit card, check or cash) to pay for deductibles or co-pays. Your co-pay or deductible must be paid at the time of service.

Our office files your insurance as a courtesy. We recommend that you should review and understand your insurance policy. Your insurance policy is a contract between you and your insurance company. It is not a contract between you and our doctors.

Should your insurance carrier withhold payment or partial payment of your claim for any reason, we will be glad to assist you in obtaining an explanation from them. However, we cannot guarantee payment of your claim. Also, we cannot be responsible for negotiating fees or claims with insurance companies or any other entity. Patients are responsible for payment of medical care within a reasonable time, regardless of the status of the claim.

If pre-authorization is needed, then it is your responsibility to notify our staff so we may obtain authorization. If no authorizations are on file, we cannot provide the services unless you decide to pay for visit at self-pay rate. Patient balances are expected to be paid in full.

We do not have payment plans for outstanding balances. Partial balance payments through the mail will not be accepted.

If you have any questions or are not prepared to pay for your appointment, please notify one of our staff prior to your appointment. If you are unable to pay for residual balances from previous dates of services, you may be asked to reschedule your appointment.

There is a $50.00 fee for missed appointments (unless a 24-hour notice is given) or more than l5 min late arrival.

There is a $25.00 for printing medical records (first 100 pages then additional 30cents/per page).

There is a placement fee of thirty dollars ($30.00) in addition to the balance subject to collection.

By printing my name below I acknowledge that I agree with the Payment Policies.

Patient Name

Date:

AUTHORIZATION TO DISCUSS HEALTH AND MEDICAL INFORMATION

Patient Name

Date of birth:

Parent or Legal Guardian

If I am not present, I authorize Dr. Tudor Scridon, MD FACC and staff to disclose my relevant health information with the persons named below.

1. Name
Relationship
Cell Phone Number
Format: 123-456-7890

2. Name
Relationship
Cell Phone Number
Format: 123-456-7890

3. Name
Relationship
Cell Phone Number
Format: 123-456-7890

4. Name
Relationship
Cell Phone Number
Format: 123-456-7890

I understand that this authorization is valid and in effect until such time as I withdraw it in writing or in person, or one year following date of signature

I understand that I can revoke, update, or change this written authorization at any time in writing.

The termination to release health and medical information is effective on the date the physician(s) office receives it in writing.

I decline to name family members and/or friends why my provider(s) and staff my discuss my health information with at this time.

However, I understand that I can always authorize provider(s) and staff to discuss my health information with family members and/or friends in writing at a later date.

By printing my name below I acknowledge that I agree with the Authorization to discuss health and medical information.

Patient Name or Legal Representative/Guardian

Authority or relationship of representative

Date:

MEDICAL CONSENT - ASSIGNMENT OF BENEFITS - RELEASE OF INFORMATION

I hereby authorize Dr. Tudor Scridon, MD, FACC to provide medical care for the herein named patient.

I hereby authorize Dr. Tudor Scridon, MD, FACC to release medical information from examination or treatment to any insurance, government agency providing benefits or other policies to process any claims on my behalf for payment.

I hereby assign and authorize my insurance carrier(s) to make payment directly to Dr. Tudor Scridon, MD, FACC for services rendered.

I understand I will be charged an additional fee of:

1. Twenty-five dollars ($25.00) for any check or draft dishonored by any financial institution.

2. In the event of collection placement of my account, I understand that I will be charged a placement fee of thirty dollars ($30.00) in addition to the balance subject to collection.

3. There is a $50.00 fee for missed appointments (unless a 24-hour notice is given) or more than 15 min late arrival.

4. There is a $25.00 for printing medical records (first 100 pages then additional 30 cents/per page.)

By printing my name below, I understand that I am ultimately responsible for payment in full of all services rendered in the event my insurance carrier and or managed care plan denies payment in full or part of any services rendered.

Patient Name or Legal Representative/Guardian

Date:

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES RECEIPT: We keep a record of the health care information related to you and we will not disclose your record to others unless you direct us or unless the law authorizes or compels us to do so. You may see your records or get more information about them by contacting the office manager. Notice of Privacy Practices describes in greater detail how your health information maybe used and disclosed, and how you can access your information. By my signature below I acknowledge receipt of the Notice of Privacy Practices.

By printing my name below, I acknowledge the privacy practice.

Patient Name or Legal Guardian

Date:

AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION THROUGH DRCONNECT

Cleveland Clinic DrConnect Operations

3175 Science Park

Beachwood, OH 44112

Phone: 877.224.7367 (877.CCHS.EMR)

Fax: 216.445.9668

Email: drconnect@ccf.org

Patient Name

Social Security Number
Format: 123-45-6789

Date Of Birth

Clinic #

Address

City

State

Zip
Telephone
Format: 123-456-7890

I hereby authorize the Cleveland Clinic and its affiliates (collectively , "Cleveland Clinic") to release my health information as indicated below. I understand and acknowledge that this release will include records of any treatment I have received for physical and mental illness,alcohol/drug abuse, and or HIV/AIDS test results, diagnoses and treatment. This authorization does not include permission to release Psychotherapy Notes as defined below. *The release of Psychotherapy notes requires a separate authorization.

Release To

Telephone
Format: 123-456-7890

Address

City

State

Zip
Reason for disclosure

Information to be disclosed: I understand and agree that my complete and full medical record will be released regardless of dates of treatment. The information released will include, but not limited to, the following records:

*Alcohol and/or drug abuse treatment records.

*Mental health treatment records including treatment for mental illness.

*HIV test, results, diagnosis and treatment.

*Discharge summaries.

*History and physical.

*Laboratory reports.

*Operative reports.

*Pathology reports.

*Medications

*Clinic/Progress notes.

Diagnoses

This authorization is subject to revocation at any time except to the extent the action has been taken thereon. I may revoke this authorization at any time by contacting Cleveland Clinic at the information listed above. I understand that the receipt of my health information may be charged for the service of releasing medical information.

This authorization will expire one hundred eighty-five (185) days from the date written below, unless I specify an earlier date:

Specify Earlier Date (Optional)

I understand that information released pursuant to this authorization may remain part of my permanent medical record at Recipient. My health care (or payment for care) will not be affected by whether or not I sign this authorization. Once my health information is released, redisclosure of my health information by the Recipient may no longer be protected by law.

NOTICE TO RECIPIENT OF INFORMATION & ADDITIONAL PATIENT ACKNOWLEDGEMENT

The information disclosed pursuant to this authorization will contain any and all information contained in my medical record that is protected by Federal Confidentiality rules relating to treatment provided by Alcohol and Drug Abuse Program (42 C.F.R. Part 2) and state law pertaining to the disclosure of HIV/AIDS information. These rules prohibit Recipient from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2 relating to the disclosure of alcohol and drug abuse program information or state law pertaining to disclosure of HIV/AIDS information. A general authorization for the release of medical or other information is NOT sufficient for these purposes. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

By printing my name below I acknowledge that I agree with the AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION THROUGH DRCONNECT

Patient Name/Patient's Personal Representative

Date Signed

Relationship if not Patient

*Psychotherapy Notes are defined as notes that document private, joint, group, or family counselling sessions that are separated from the rest of a patient's medical record.

If other than the patient's signature, a copy of legal paperwork verifying the patient's personal representative MUST** accompany the request(i.e court appointed guardian, durable power of attorney for health care). For a deceased patient: A death certificate coupled with executor or administrator of estate paperwork must accompany authorization. Exception: parent signing for patient under the age of 18.

(772) 226-7380

1300, 36th St, Unit D, Vero Beach

FL, 32960

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