Advance Directive

All adults in health care settings in the State of Florida have the right to an "advance directive." This is a written or oral statement made and witnessed in advanced of a serious illness or injury, stating how medical decisions will be made . An advance directive enables you to state your choice or name someone to make your choice for you, if you should become unable to make decisions about your medical treatment. An advance directive can enable you to make decisions.

Do you have a living will? ___Yes ___No

Authorization for Release of Confidential Information

I hereby authorize Peter Weissgerber, MD, P.A., to release medical, psychiatric and substance abuse (if any) information contained in my/the patient's records to my insurance company for the purpose of obtaining information and/or reviewing the record of medical care received by the patient and for the payment of all medical charges. Copies of these records may also be sent to referring physicians at the request of physicians treating me/the patient.

Unless noted below, medical records released may include diagnostic and therapeutic information (including any tests for the IV antibody/substance abuse or treatment in regard to either of the aforementioned).

Withhold from release (please specify if any):
______________________________________________________________________

This consent will remain in force unless it is revoked by me in writing. Information is disclosed from records whose confidentiality is protected by Federal or State law. Federal regulations or state law prohibit making any further disclosure of HIV antibody/substance abuse without the specific written consent of the person to whom it pertains, or as otherwise permitted by Federal/State law.

Date:____________________

________________________________________       ____________________________________
Patient's Signature or Authorized Representative       Print Name

________________________________________
Relationship to the Patient

Witness (print name):______________________

Witness Signature:________________________            Date:________________

The patient hereby consents to the use or disclosure of his/her individually identifiable health information ("protected health information") and patient medical record information by Peter W. Weissgerber MD, P.A. ("the Practice") in order to carry out treatment, payment or health care operations. The Patient should review the Practice's Notice of Privacy Practices for a more complete description of the potential uses and disclosures of such information. The Patient has the right to review such Notice prior to signing this Consent Form.

The Practice reserves for itself the right to change the terms of its Notice of Privacy Practices at any time. If the Practice does change the terms of its Notice of Privacy Practices, Patient may obtain a copy of the revise notice.

Patient retains the right to request that the Practice further restrict how his/her protected health information is used or disclosed to carry out treatment, payment or health care options. The Practice is not required to agree to such requested restrictions; however, if the Practice does agree to Patient's requested restrictions(s), such restrictions are then binding on the Practice.

Patient acknowledges and agrees that the Practice may disclose Patient's protected health information and patient medical record information to the following individuals who are either the Patient's family members, legal representatives, guardians, health care surrogates, or have power of attorney on behalf of the Patient:
___________________________________________________________________________
___________________________________________________________________________

The Patient agrees that the Practice may disclose information contained in the Patient's medical records including all types listed below, unless otherwise designated. Please initial exclusions:
____HIV/AIDS Information   ____Mental Health Information   ____Substance Abuse Information
Patient agrees and consents to the Practice releasing information to Patient, including the following alternative manners, unless otherwise designated. Please initial exclusions:
____Via facsimile
____Via Regular Mail with any envelopes being marked personal and confidential and addressed to the  Patient.
____Via telephone, if Patient contacts the Practice and provides the appropriate information (including the Patient's name, Social Security Number and unique personal identifier).

At all times, Patient retains the right to revoke this Consent. Such revocation must be submitted to the Practice in writing. The revocation shall be effective except to the extent that the Practice has already taken action in reliance on the Consent.

Print Patient Name:___________________________ Signature:_____________________________

The Practice may refuse to see a patient if he/she (or an authorized representative) does not sign the Consent Form. If the patient (or authorized representative) signs the Consent and then revokes it, the Practice has the right to refuse to provide further treatment to the patient as of the time of revocation (except to the extent that the Practice is required by law to treat individuals).

I HAVE READ AND UNDERSTAND THE INFORMATION IN THE CONSENT. I AM AWARE THAT I MAY REQUEST A COPY OF THIS CONSENT, AND I AM THE PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OT HE PATIENT, TO SIGN THIS SEALED DOCUMENT VERIFYING CONSENT OT THE ABOVE STATED TERMS.

Date:___________ Time:______AM/PM
_______________________________________
Signature of Patient (or authorized person)
Representative*_________________________(Please Print Name)
*Please explain representative's relationship to the Patient and include a description of the representative's authority to act on behalf of the patient:
_____________________________________________________________________
___________________________________________________________________________________

Payment Policy and Assignment of Insurance Benefits

Our policy is that payment is expected IN FULL at the time that services are rendered. Financial arrangements are to be made prior to treatment.

If you participate with one of our contracted insurance programs, we will bill your insurance company; however, you will be responsible for your deductible and co-payments at the time of your office visit. Therefore, verification of your insurance deducible, and CO-payments in advance of your office visit will be necessary.

If you have any questions or need to make any financial arrangements, please speak with our accounts manager or office manager in advance.

I understand and agree to comply with Dr. Peter Weissgerber's financial policy.

Signature:____________________________________   Date:________________________

Print Name:___________________________________

Assignment of Insurance Benefits

I authorize the release of any medical or other information necessary to process my claims. I assign payment directly to the physicians, the benefits which may be due to me from the Medicare program or any other insurance product including supplemental insurance, which may cover in whole or in part, medical services which I have received and will assist in the collection of my insurance should there be any delay in payment. If my insurance payment is not received in thirty (30) days, I agree to actively and vigorously pursue collection the payment for the physician. I understand that I am financially responsible to the physician for charges that may not be covered in part or in full by my insurance company.

Signature:__________________________________   Date:_______________________

Acknowledgment Form

Our Notice of Privacy Practice provides information about how we may use and disclose protected health information about you. You have the right to review our Notice before signing this form. As provided in our Notice, the terms of our Notice may change. If we change our Notice at any time, you may obtain a copy by request. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations as described in our Notice. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

Patient Name (print): __________________________

Signature:___________________________________ Date:______________

Witness:____________________________________