Jennifer Forrest, MD, Brinceton M. Phipps, MD

CONSENT OF DISCLOSURE

For the Usage and/or Disclosure of Protected Health Information

I hereby give my consent to Animas Orthopedic Associates and Sports Medicine (AOA) to use and disclose my protected health information (PHI) for the purposes of treatment, payment and health care operations (TPO).

AOA's Notice of Privacy Practices provides more detailed information about usage and disclosure of my protected health information. I have the right to review the Notice before I sign this consent. AOA reserves the right to amend its Notice of Privacy Practices. I may obtain a copy of the current policy by contacting AOA at (970) 259-3020.

I have the right to request restrictions on the usage and disclosure of my protected health information for the purpose of treatment, payment or health care operations. AOA is not required to grant my request, however, if AOA does, it is bound by this agreement.

I understand with respect to payment for treatment received, that although I may be covered by insurance. I am personally responsible for all charges, unless the charges are covered under workers' compensation insurance.

I may cancel this consent in writing except to the extent that AOA has already made disclosures in reliance upon my prior consent.

If I do sign this consent, Animas Orthopedic Associates and Sports Medicine may decline to provide treatment to me.

Signature of Patient / Legal Guardian:_______________________________________________

Date:__________________________

Print Patient's Name:_____________________________________________________________

Print Name of Legal Guardian:____________________________________________________

 575 Rivergate Lane, Suite 105

Durango, Colorado 81301

Mark H. Kircher, MD,  Paul D. Dvirnak, MD,  Field T. Blevins, MD

Jennifer Forrest, MD

Patient Information

Date:_________________________

Patients Name:____________________________Age:_______Date of Birth______________

Home Address:______________________________________________________________________________________

                                        Street Address or PO Box                                      City          State            Zip Code

Mailing Address (if different)_____________________________________________________

Home Phone: (______) ___________________   Cell Phone (______) ___________________

Work Phone: (______) ___________________Message Phone: (______)_________________

Sex: M / F Social Security #:_________________Marital Status (circle one) S M W D Sep

Employed: Yes / No           Student: Yes / No           Retired: Yes / No

Employer: ___________________________Work Phone: (______) _____________________

Address: ______________________________________________________________________

Spouse's Name:_______________________Spouse's Phone #: (______)________________

Emergency Contact:__________________________________Relationship:___________________________

Home Phone: (______) ______________________Work Phone: (______) ________________

INJURY INFORMATION ▬ Date of Injury:________State where injury occurred:________

Location of Pain:______________________Circle one: Left Side / Right Side / Both Sides

Type of Injury: (circle one): Job Related / Auto Accident / Other_____

                                         Lawyer Involvement: YES / NO

Referred by:___________________________Primary Care Physician:__________________

MEDICATION INFORMATION: ▬ Drug Allergies:____________________________________

Current Medication:____________________________________________________________

I authorize Animas Orthopedic Associates to release any medical information requested by my insurance company to process a claim. I authorize my insurance company to pay, directly to the physician, all benefits due to me under the provisions of my policy. I understand and accept that, although I may be covered by insurance, I am personally financially responsible for all charges incurred for services rendered to me.

Signature:________________________________________ Date:_______________________