PRIVACY POLICY & DISCLOSURES TO THIRD PARTIES
There may be times when it would become necessary for an individual directly involved in your care to inquire about your personal health information or billing/payment information. Parents, guardians, spouse, family members or other healthcare providers may be among those making such an inquiry. PM/METHOD, LLC respects your privacy and confidentiality rights and will not release personal health information or billing/payment information without your consent and authorization to do so.
For purposes of such disclosures to such individuals, please execute the following authorization and designate the individuals to whom release of your personal health information is authorized:
I authorize PM/METHOD, LLC to disclose my personal health information that is directly related to my current treatment to the individual(s) listed below for purposes of their role in my treatment or payment for the services that I have received:
NAME RELATIONSHIP
______________________________________________
1.
2.
3.
Signature: _______________________
Date: _____________
///////////////////////////////////////////////////////////////
I do not wish to have my health information disclosed to the following individuals:
NAME RELATIONSHIP
______________________________________________
1.
2.
3.
Signature: _______________________. Date: ______________