MIME-Version: 1.0 Content-Location: file:///C:/D9279A45/New_PTHIPPAandAuthorization1.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" HIPPA policy acknowledgement and Insurance Benefits and Information Release

Lone St= ar Physicians Group, P.A.

 

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I hereby acknowledge that I have read the HIPPA policies and rece= ived a copy (if requested) for Lone Star Physicians Group, P.A.

 

Also, I hereby authorize the physician to release any and all information necessary concerning my diagnosis and treatment for the purposes of securing payment from my insurance company; and thereby authorize payment of the insurance benefits directly to the physician for any services rendered that are not paid for directly by me.

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Signatu= re of the parent/guardian

Date

Parent/= Guardian’s Name

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Child/patient Name: <= /span>

 

Child’s date of birth:

 

Authorization to Tre= at Minor

 

 

 

As the parent/guardian of the above-named child, I hereby give permission to Iresh Kumar, MD to treat my child in the event that a medical emergency arises and I am unable to personally consent to the treatment. I also agree to be respons= ible to the physician for charges for medical services rendered.

 

Signatu= re of the parent/guardian

Date

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Parent/= Guardian’s Name

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