Common use of CERTIFICATION AND AUTHORIZATION Clause in Contracts

CERTIFICATION AND AUTHORIZATION. I certify that the above information is correct. I authorize the release of any medical information necessary to process insurance claims. I request that payments be made directly to ▇▇▇▇▇▇▇ & Associates, P.C. on my behalf. Therefore my signature will be on file with my insurance company. SIGNATURE: DATE: I have been provided a Notice of Privacy Practices that fully explains the uses and disclosures that ▇▇▇▇▇▇▇ and Associates, P.C. will make with respect to my individually identifiable health information. I understand that I have the right to review the Notice before signing this consent. ▇▇▇▇▇▇▇ and Associates, P.C. has afforded me sufficient time to review this Notice and has answered any questions that I have to my satisfaction. I also understand that ▇▇▇▇▇▇▇ and Associates, P.C. cannot use or disclose my individually identifiable health information other than as specified on the Notice. I also understand, however, that ▇▇▇▇▇▇▇ and Associates, P.C. reserves the right to change its notice and the practices detailed therein prospectively (for uses and disclosures occurring after the revision) if it sends a copy of the revised notice to the address that I have provided. ▇▇▇▇▇▇▇ and Associates, P.C. utilizes cellular telephone communication. Due to the nature of cellular telephone communication, telephone calls on cellular telephones are subject to the possibility of unintended disclosure. Therefore, calls made on cellular telephones can not be considered secure. ▇▇▇▇▇▇▇ and Associates, P.C. will not disclose Protected Health Information on cellular telephones unless specifically requested to do so by patients.