HIPPA FORM

SOL MEDICAL GROUP

AUTHORIZATION TO RECEIVE INFORMATION (Choose 1)
I DO NOT authorize anyone other than myself to receive information regarding my healthcare.
I DO authorize the following person (s) to receive information regarding my healthcare
NAME / RELATIONSHIP TO PATIENT
NAME / RELATIONSHIP TO PATIENT
NAME / RELATIONSHIP TO PATIENT
Please indicate one of the following:
I DO give permission for SOL Medical Group to leave information regarding my personal health information on my voice mail or answering machine.
I DO NOT give permission for SOL Medical Group to leave information regarding my personal health information on my voice mail or answering machine.
I DO give permission for SOL Medical Group’s EMR to send text messages and voice messages regarding my appointments.
I DO NOT give permission for SOL Medical Group’s EMR to send text messages and voice messages regarding my appointments.
AUTHORIZATION TO PAY BENEFITS & ACCEPTANCE OF PAYMENT POLICY.
I authorize payment directly to the physicians of SOL Medical Group for any surgical or medical benefits payable to me for services provided. I understand that I am responsible for payment for the services provided by SOL Medical Group. SOL Medical Group will file the charges with my insurance plan. I accept responsibility for these charges not covered by my plan. And I agree to pay those charges on receipt of statement. I understand that I am responsible for any co-payment due at time of service. I authorize SOL Medical Group to release any information acquired during my examination or treatment for insurances purposes. I have read all the information above and agree to these terms.
Name
First Name
Last Name
Default label
Month
Day
Year
Relationship to Patient

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.