I understand that I have the right to review Bellevue Pain and Wellness PLLC Notice of Privacy Practices prior to submitting this form. I understand that Bellevue Pain and Wellness PLLC reserves the right to change their notice and practices and I may be given or may request new notification if this occurs. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations, and the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance theron.
I understand that I am authorizing the release of all or any part of my medical record for the purposes of treatment, payment, or practice operations. This release may include records containing information regarding the diagnosis and/or treatment of HIV/AIDS, mental illness, and/or drug and/or alcohol addiction or abuse to any person or corporation which is or may be liable under a contract for all or part of the medical charges, including but not limited to: Medicare, Medicaid, DSHS, or other private or public health insurance programs, reviewing agenes, worker’s compensation carriers, welfare agencies or the patient’s employer. The records may be needed in order to process a claim for medical services.
I authorize Bellevue Pain and Wellness PLLC and its representatives to release information needed for billing purposes to entities that may provide services pertaining to my health care visit, such as reference laboratories by submitting this form.