Fillable AUTHORIZATION PATIENTS INFORMATION Date of Birth Full Name

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AUTHORIZATION PATIENTS INFORMATION Date of Birth Full Name

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The AUTHORIZATION PATIENTS INFORMATION Date of Birth Full Name form is 1 page long and contains:

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  • 9 other fields

Country of origin: OTHERS
File type: PDF

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Patient
Authorization |HIPAA Form
Completed form may be sent via Fax: 336.740.9773 or via e-mail: einfo@emsbilling.com
PO Box 863 Lewisville, NC 27023
-
0863 |Customer Service: 800.814.5339
PATIENT’S INFORMATION
AUTHORIZATION
I hereby authorize EMS Management & Consultants, Inc. to use or disclose the following Protected Health
Information: Ambulance Call Report and/or Bill(s).
DISCLOSURE
I understand that I have the following rights:
• To inspect and copy the information to be used or disclosed according to this authorization.
• To revoke this authorization at any time except for instances where EMS Management & Consultants, Inc.
has already used or disclosed information subject to this authorization.
• To revoke this authorization, I must provide written notice to:
Privacy Officer
EMS Management & Consultants, Inc.
PO Box 863
Lewisville, NC 27023
Phone: 800.814.5339 | Fax: 336.740.9773 | E-mail: einfo@emsbilling.com
Information used or disclosed according to this authorization may again be disclosed by the recipient. This
information is no longer protected by privacy law.
Written authorization is not required for treatment, payment or healthcare operations.
I have read this authorization and I understand I have the right to refuse to sign it. I understand and agree to the
terms of this authorization.
This form implements the requirements for patient authorization to use & disclose health information protected by the federal health privacy
l
aw, 45 CFR, parts 160, 164. Except as otherwise permitted or required by the privacy law, a health care provider subject to the privacy law may
not use or disclose protected health information without an authorization that complies with the requirements of 45 CFR, 164.508(c).
Full Name
Social Security Number
Date of Birth
Run Number | EMS Company Name
This may be used or disclosed to:
The Purpose for the use or disclosure is:
Patient’s Signature
Date Signed
Or, if applicable check Next of Kin if you are and if patient is deceased
Next of Kin Personal Representative Signature
Relationship to Patient
Date Signed
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AUTHORIZATION PATIENTS INFORMATION Date of Birth Full Name

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Completed 24 July 2021

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