CONSENT TO USE OR DISCLOSE HEALTH INFORMATION DATE:
I __________________________ authorize Horizons Medical Supplies, LLC. to use and disclose the health and medical information of _______________________________________for the purposes of Treatment, Payment and Health Care Operations. Treatment (includes activities performed by a healthcare provider, practitioner, office staff, and other types of healthcare professionals providing care to you, coordinating or managing your care with third parties, and consultations with and between our health care providers. This consent includes treatment provided by any health care provider who covers my/our facility by telephone as the on-call provider.) * Payment (includes activities involved in determining your eligibility for health plan coverage, billing and receiving payment for your health benefit claims, and utilization management activities which may include review of health care services for medical necessity, justification of charges, pre-certification and pre-authorization.) * Health Care Operations (including the necessary administrative and business functions of our office.) You may review Horizons Medical Supplies and Homecare, LLC . “Notice of Privacy Practices” for additional information about the uses and disclosures of information described in this Consent prior to signing this Consent. Please verify that you have received a copy of our Notice by your initials here: _________. Because we have reserved the right to change our privacy practices in accordance with the law, the terms contained in the Notice may change also. A summary of the Notice will be posted in our store indicating the effective date of the Notice in the upper right hand corner. We will offer you a copy of the Notice on your first visit to us after the effective date of the current Notice. We will also provide you with a copy of the Notice upon your request. As more fully explained in the Notice, you have the right to request restrictions of how we use and disclose your protected health information for treatment, payment, and health care operations purposes. We are not required to agree to your request. If we do agree, we are required to comply with your request unless the information is needed to provide you emergency treatment. Other providers who provide on-call coverage for our store are required to use and disclose your protected health information consistent with the Notice. Name someone authorized by you to handle your account should you be unable to do so. You must print neatly.
I hereby acknowledge that I have received and read this Notice of Privacy Practices.
170 S. Semoran Blvd, Orlando FL 32807
Phone 407-240-8600 Fax: 407-386-8711
Saturday & Sunday Closed
Copyright © 2017 Horizons Medical Supplies & Homecare, LLC - All Rights Reserved.
Family Owned and Operated