About You

 
 
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Person Responsible for Account

 
 
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Insurance Company Information

 
 
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***If there are secondary insurance benefits, please let us know.***
 

Patient/Doctor Agreement

 

I hereby agree to pay all charges if the insurance company does not pay in full within 60 days.I will pay the balance in full or make arrangements to pay on a monthly or weekly basis.

 
 
 

Acknowledgement of Privacy Policy and Practices

 

I understand that in an attempt to protect the privacy of my identifiable health information, Drs.Akel and Favale,P.L. has established a Privacy Policy and guidelines of Privacy Practices within this office.This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purpose of diagnosis,treatment,payment and health care operations. In accordance with HIPPA Regulations,a copy of the Privacy Policy & Practices has been made available to me while in the office today.Should I choose to have a personal copy, one will be given to me at no charge.

  • I have read,I understand,and I acknowledge the Privacy Policy & Practices of Drs. Akel and Favale,P.L.
  • I have elected not to read the Privacy Policy & Practices of Drs. Akel and Favale,P.L.
  • A copy of the Drs.Akel and Favale,P.L.Privacy Policy & Practices

 

Patient Consent for Use and Disclosure of Protected Health Information

 

I hereby give my consent for Drs.Akel and Favale, P.L. to use and disclose protected health information (PHI) about me to carry out treatment,payment and healthcare operations(TPO).

Drs. Akel and Favale, P.L.’s Notice of Privacy Practices provides a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Drs. Akel and Favale, P.L.’s reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice may be obtained by forwarding a written request to Drs. Akel and Favale, P.L. Privacy Officer,Anthony Favale at 953 Lane Avenue South, Jacksonville, Florida 32205.

By signing this form, I am consenting to Drs. Akel and Favale, P.L.’s use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.If I do not sign this consent,or later decline it, Drs. Akel and Favale, P.L.,may decline to provide treatment to me.