INSURANCE INFORMATION

If you have given the front desk a copy of your insurance card, then you do not need to fill the insurance portion of this form out.

Please Indicate Primary Insurance

INCASE OF EMERGENCY Contact

Please Read & Sign Below:

I directly assign all Medical/Surgical benefits to Fawad S. Zafar, M.D. & understand that I am financially responsible for all charges whether or not paid by insurance. I understand that payment is due within 30 days of receiving an invoice. I further understand That Lakeview Center for Urology will not check my insurance benefits.

I here by authorize Dr. Zafar to release all information necessary to secure the payments of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.

Medical History Questionnaire

Lakeview Center for Urology

Fawad Zafar, MD
1000 73rd St. Ste.17 West Des Moines, IA 50265

PLEASE FILL THIS FORM OUT ENTIRELY. IF SOMETHING ON THIS FORM DOES NOT PERTAIN TO YOU, THEN
PLEASE WRITE N/A.

SOCIAL HISTORY

HIPAA/ DISCLOSURE OF HEALTH INFORMATION

Notice to Patient:

By signing this form, you grant us consent to use and disclose your protected healthcare information for the purposes of treatment, various activities associated with payment and healthcare operations. Our Notice of Privacy Practices provides more details on our treatment, payment activities and healthcare operations. If there is not a copy of the Notice accompanying this Consent form, please ask for one. We encourage you to read it since it provides details on how information about you may be used and/or disclosed and describes certain rights you have regarding your health care information.

As stated in our Notice of Privacy Practices, were serve the right to change our privacy practices. If we should do so, we will issue a revised Notice. Since revisions may apply to your health care information, you have a right to receive a copy by contacting our Privacy Officer.

You have the right to revoke your Consent by giving written notice to our Privacy Officer. There vocation will not affect actions that were already taken in reliance upon this Consent. You should also understand that if you revoke this Consent we may decline to

Treat you. You are entitled to a copy of this Consent Form after you have signed it.

(To Be Completed by Patient or Patient’s Representative)

Have read the contents of this Consent Form and the Notice of Privacy Practices. I understand that I am giving you my consent to use and disclose my health care information to carry out treatment, payment activities and health care operations. This information may be released to:

I do not authorize the release of my information.

MESSAGES

HIPPA Consent for Use / Disclosure of Health Information

This form does not constitute legal advice and covers only federal, not state, laws.