[wr_row width=”boxed” background=”none” solid_color_value=”#FFFFFF” solid_color_color=”#ffffff” gradient_color=”0% #FFFFFF,100% #000000″ gradient_direction=”vertical” repeat=”full” img_repeat=”full” autoplay=”yes” position=”center center” paralax=”no” border_width_value_=”0″ border_style=”solid” border_color=”#000″ div_padding_top=”10″ div_padding_bottom=”10″ div_padding_right=”10″ div_padding_left=”10″ ][wr_column span=”span12″ ][wr_heading el_title=”Authorization for Care and Release” tag=”h2″ text_align=”center” heading_margin_top=”25″ heading_margin_bottom=”25″ font=”inherit” enable_underline=”yes” border_bottom_style=”solid” appearing_animation=”0″ disabled_el=”no” ]Authorization for Care and Release[/wr_heading][wr_text text_margin_top=”0″ text_margin_bottom=”0″ enable_dropcap=”no” appearing_animation=”0″ disabled_el=”no” ] Patient Name Date of Birth SSN Patient Address Telephone Numbers: (C) (H) (W) Any previous Imaging of the body part being examined today? YN IF YES, WHERE? WHEN? I authorize: to release to American Imaging. This authorization for release of information is valid indefinitely from the date of signature unless revoked by written notice to the providing institution. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to consent a claim under my policy. I understand that once the information is disclosed pursuant to this authorization, the recipient may re-disclose it and the authorization will not affect my Ability to obtain treatment, receive payment, or eligibility for benefits unless allowed by law. I grant permission for the employees of American Imaging of Southwest Florida to render care to me and expedite the orders of the physicians and or physician extender. I authorize release of this information to other healthcare providers associated with my care. I permit/refuse , to discuss my medical record and/or billing information. I authorized American imaging of Southwest Florida to furnish information to insurance carriers concerning my care. I Agree to pay an American imaging of Southwest Florida for all services rendered to my dependents or myself. I understand that I am responsible for any amount not covered by my insurance and if I have not secured a proper authorizations and otherwise complied with the terms of my benefit plan, there may be a decrease or no coverage at all for services rendered at American imaging of Southwest Florida. For self-pay patients I also understand that I am responsible for all services rendered to my dependents or myself. Co-pays and self-pay charges are due at the time of service. Outstanding balances referred to a collection agency will be assessed an additional fee equal to the collection fee no greater than 35% of the balance owed. Patient Signature: X Date Email authorization I hereby authorize American Imaging of Southwest Florida to email me at, E-mail with current practice updates whenever possible. I understand that American Imaging of Southwest Florida will not share my email address with any other persons or agencies. This authorization will remain in effect until I revoke this authorization in writing. Patient Signature: X Date Acknowledgment of Receipt of Notice of Privacy Practices Your name and signature on this section indicates you received a copy of American Imaging of Southwest Florida's notice of privacy practices on the date indicated if you have any questions regarding the information in your notice of privacy practices, please do not hesitate to contact our privacy officer at 941–235–8762. Patient Signature: X Date [/wr_text][/wr_column][/wr_row]