Patient Information Update Form

CONFIDENTIAL PATIENT INFORMATION SHEET

PATIENT INFORMATION

 
 
 
SINGLE 
 
MARRIED 
 
WIDOW 
 
SEPARATED 
 
DIVORCED 
 
OTHER 

PRIMARY INSURANCE

 
SELF 
 
SPOUSE 
 
CHILD 
 
OTHER 


 
 
 
 
 
 


Release of Information

This authorization will permit South Atlanta Neurology and Spine Clinic to release any and all information pertaining to my health and well-being. I hereby authorize South Atlanta Neurology and Spine Clinic to release my information to any insurance company for the purpose of determining eligibility or for payment of benefits. I authorize South Atlanta Neurology and Spine Clinic to disclose protected health information (PHI) about me to the following person/people:


(There must be a date of expiration, ex. 10-100 years, divorce, death, etc.)

I understand that when my PHI is used or disclosed pursuant to this authorization, it may be subject to disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to: South Atlanta Neurology and Spine Clinic, 518 Eagles Landing Parkway, Stockbridge, GA 30281.