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ALLIANCE: 330-821-3244 | CANTON: 330-492-8117 | MINERVA: 330-868-3711
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MASTER CONSENT
FORM
I have read and understand the HIPAA/Privacy Policy for IMP (copy available on request).
I authorize IMP to release my insurance company medical information required to process claims.
I hereby assign my insurance benefits to be paid directly to the healthcare provider.
I have read and understand the financial/office policies for IMP (copy available upon request)
I authorize IMP to obtain/have access to my medication history through medical history authority.
I authorize IMP to contact me by the means I have selected (i.e. telephone, text, email)
I authorize IMP to use Impact SIIS for reporting vaccines I receive to the State of Ohio Department of Health. (This is for our office inform the Ohio Department of Health when you receive a vaccine.)
I authorize IMP to use Impact SIIS for reporting vaccines I receive to the State of Ohio Department of Health. (This is for our office inform the Ohio Department of Health when you receive a vaccine.)
Yes
No
I authorize IMP to exchange my healthcare information with my other healthcare providers through an encrypted electronic data exchange. (This is for us to be able to send your medical information when we refer you to another doctor.)
Yes
No
I authorize IMP to take photographs and use those images taken for diagnostic and treatment purposes. (For example, your provider may take a picture of a mole or rash in order to determine at a later date if the condition has improved or progressed.)
Yes
No
MY PRIMARY CARE PROVIDER IS
IN WHICH OFFICE
My signature implies consent to the above statements.
Signature
Clear
DATE
PRINTED NAME
DATE OF BIRTH
SUBMIT
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