Foot and Ankle Alliance

23170 Ventura Blvd, Woodland Hills, CA 91364

18366 Clark St., Suit # 106, Tarzana, CA 91356

Tel: (818) 914-5689 | Fax: (818) 914-4573

www.fixmyfoot.com | drk@fixmyfoot.com

PATIENT INFORMATION
MEDICAL HISTORY
FAMILY MEDICAL HISTORY
INSURANCE INFORMATION
PATIENT SURVEY
HIPAA CONSENT FORM

1. OUR LEGAL DUTY:

We are required by law to protect the Privacy of your health information, to provide a notice concerning Privacy practices, to follow the Privacy practices that we describe in our Notice of Privacy, and seek your acknowledgement of receipt of this notice.

2. HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION:

By signing this form, you consent to our use and disclosure of protected health information about your treatment, payment, and health care operations.

3. YOUR RIGHTS:

You have the right to look at or get a copy of your health information, and if you request a copy, we may charge you a fee. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or request that we correct the information or add any missing information.

ASSIGNMENT & RELEASE:

I, the undersigned certify that I (or my dependent) have insurance coverage with above insurance company(s) and assign directly to Dr. Alireza Khosroabadi all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance.


INSURANCE INFORMATION

ASSIGNMENT & RELEASE

I, the undersigned certify that I (or my dependent) have insurance coverage with the above insurance company(s) and assign directly to Dr. Alireza Khosroabadi all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits.

I authorize the use of this signature on all insurance submissions. I also certify that I have read and understand the HIPAA PATIENT CONSENT FORM. I certify that the above information is true and correct to the best of my knowledge. I give my permission to the doctor to administer and perform such procedures as may be necessary in the diagnosis and/or treatment of my feet and ankles.

CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY

I, , whose signature appears below, authorize Dr. Alireza Khosroabadi and affiliated providers to view my external prescription history via the RxHub service.

I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and staff here, and it may include prescriptions back in time for several years.

MY SIGNATURE CERTIFIES THAT I READ AND UNDERSTOOD THE SCOPE OF MY CONSENT AND THAT I AUTHORIZE THE ACCESS.


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