CARDIOTHORACIC SURGICAL SPECIALISTS 1245 BRACE RD

CHERRY HILL, NJ 08034 DR. AMRIT NAYAR

PATIENT PRIVACY ACKNOWLEDGEMENT: I RECEIVCED AND UNDERSTAND THE CARDIOTHORACIC SURGICAL SPECIALISTS NOTICE OF PRIVACY PRACTICES. ___________________________________ _____________ _________________ SIGNATURE OF PATIENT/REPRESENTATIVE DATE TIME ________________________________________ ________________________________________ RELATIONSHIP REASON PATIENT IS UNABLE TO SIGN PATIENT IS UNABLE TO SIGN BECAUSE THE PATIENT/AUTHORIZED REPRESENTATIVE LISTED ABOVE REPRESENTED TO ME THAT HE/SHE SIGNED THIS DOCUMENT. ________________________________________________________________________________________________ NAME OF WITNESS AND SIGNATURE DATE RELEASE OF INFORMATION FOR PAYMENT/ASSIGNMENT OF BENEFITS

I UNDERSTAND THAT CARDIOTHORACIC SURGICAL SPECIALISTS MAY DISCLOSE MY PROTECTED HEALTH INFORMATION TO

CARRY OUT TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS.

I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER THE TITLE XVIII OF THE SOCIAL

SECURITY ACT OR OTHER PROVIDER(S) IS CORRECT.

IN CONNECTION WITH THE MEDICAL CARE PROVIDED TO ME AT CARDIOTHORACIC SURGICAL SPECIALISTS EXCEPT AS

OTHERWISE PROHIBITED BY LAW, BY MY SIGNATURE BELOW, I HEREBY GRANT PERMMISION FOR CARDIOTHORACIC

SURGICAL SPECIALISTS TO RELEASE MY MEDICAL RECORDS (OR OTHER INFORMATION ABOUT ME) TO THE SOCIAL SECURITY

ADMINISTRATION, (ITS INTERMEDIARIES, OR CARRIERS) OR OTHER PROVIDER(S) NEEDED FOR THIS (OR RELATED) MEDICAL

CLAIM.

I AUTHORIZE PAYMENT DIRECTLY TO CARDIOTHORACIC SURGICAL SPECIALIST FOR THE BENEFITS HEREIN SPECIFIED AND

OTHERWISE PAYABLE TO ME, BUT NOT TO EXCEED THE PRACTICE'S REGULAR CHARGES FOR THE SERVICES DESCRIBED.

I UNDERSTAND CARDIOTHORACIC SURGICAL SPECIALISTS MAY DISCLOSE ALL OR PART OF MY MEDICAL RECORDS TO

APPROVED PRACTICE STAFF, REGULATORS, GOVERMENT AGENCIES AS REQUIRED BY LAW.

______________________________________________ _________________________ SIGNATURE OF PATIENT/HEALTHCARE REPRESENTATIVE DATE ____________________________________________________________________________________________________ RELATIONSHIP TO PATIENT REASON PATIENT IS UNABLE TO SIGN THE PATIENT/AUTHORIZED REPRESENTATIVE LISTED ABOVED REPRESENTED TO ME THAT HE/SHE SIGNED THIS DOCUMENT. ____________________________________________________________________________________________________ WITNESS SIGNATURE DATE

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CARDIOTHORACIC SURGICAL SPECIALISTS 1245 BRACE ROAD

CHERRY HILL, NJ 08034 DR AMRIT NAYAR

RELEASE INFORMATION

This is to certify that I____________________________________________________________________________ request that my medical information only be released to: _____ Family _____________________________________________________________________________ Name _____ Medical _____________________________________________________________________________ Name Or ____ I do not wish to have my health related information released to anyone other than myself. ______________________________________________________________________________ Patient Signature Date Or _____ I give permission to leave messages in regards to blood work results, outside testing, appointments reminders, etc. either on my answering machine or with a family member who answers my phone. _____If I am unable to be reached by phone, no messages pertaining to myself are to be left on my home answering machine or with family members. ______________________________________________________________________________ Patient Signature Date Any change of the patient release information must be given in writing, verbal requests for changes will not be honored. Page 5