PRIVACY NOTE: Please note that we maintain a Notice of Privacy Practices, which is posted at several locations in our waiting room. We also have copies that are accessible at the front desk that we encourage you to take and familiarize yourself.

List any individuals with whom you give us permission to discuss your account and medical information, including but not limited to treatment, diagnosis, medications, test results or other types of protected health information in order to facilitate or coordinate treatment and payment for your services. You understand that the release of your information is voluntary and does not affect your access to treatment. You can choose NOT to disclose your information if you wish. You can revoke this authorization at any time by writing to Cahaba Valley Surgical Group, PC, or by filling out a new form

CONSENT FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION


The staff of Cahaba Valley Surgical Group, P.C. thank you for entrusting us with your healthcare. Please read this statement carefully and sign at the bottom of this form.

I acknowledge that I am presenting to this office for evaluation and treatment, which may include surgery, medications and diagnostic tests. I authorize the release of any medical, insurance or other information necessary to treat me and coordinate my care, to process claims on my behalf, and authorize Cahaba Valley Surgical Group to do so if I have indicated that I have insurance for my services. I assign benefits for payment of insurance claims directly to the practice. I agree to be fully responsible for all lawful debts incurred for services I receive from Cahaba Valley Surgical Group, P.C., as well as medical services provided in any hospital setting necessary, whether covered by my insurance or not, including any collections fees if I do not pay my bill. I understand that my insurance may have a deductible, coinsurance, non-covered services, and/or pre-existing condition provisions and I will be fully responsible for any patient responsibilities as indicated by my insurance company Your private health and financial information is protected by federal and state laws. We are required to uphold specific standards to protect and secure that information. By presenting to our office and signing below, you hereby consent for Cahaba Valley Surgical Group, PC to use or disclose information about yourself (or another person for whom you have the authority to sign) for the sole purposes of treatment (coordinating, arranging and delivering care, including referrals to other healthcare providers for your treatment), payment (which may include filing claims or sending statements, including medical information to support processing claims) and health care operations. You may refuse to sign this consent form.


We maintain a Notice of Privacy Practices which is posted in our office, of which copies are available to you at our registration desk.


You have the right to request that the Practice restrict how protected health information (PHI) is used or disclosed to carry out treatment, payment, or health care operations. The Practice is not required to agree to requested restrictions; however; if the Practice agrees to your requested restrictions, the restriction is binding on it.


Information about you is protected under federal law, and you have the right to revoke this Consent, unless we have taken action in reliance on your authorization. By signing below, you recognize that the protected health information used or disclosed pursuant to this Consent may be subject to re-disclosure by the recipient and may no longer be protected under federal law.

AUTHORIZATION FOR COMMUNICATIONS

I certify that I understand the privacy risks of the mail, phone calls, and e-mail. I hereby authorize a Cahaba Valley Surgical Group, PC representative or my physician direct to me by mail, telephone, e-mail, or publish to a secure encrypted website (if I so indicate) communications regarding my healthcare, including but not limited to such things as appointment reminders, referral arrangements, and laboratory results. I understand that I have the right to rescind this authorization at any time by notifying Cahaba Valley Surgical Group, PC to that effect in writing

TREAMENT CONSENT

I hereby consent to evaluation, testing, and treatment as directed by my Cahaba Valley Surgical Group, PC. physician or his/her designee

Medications: please list all current medications, dose/strength, and frequency taken–please include supplements, vitamins,& herbs

Family History: please list illness in your family

Please indicate below significant medical problems of family members. Indicate which family members by checking (X) the appropriate column.

Reproductive History (Female Patients):