Liza Maniquis-Smigel, MD

PATIENT AFFIRMATION AGREEMENT AND AUTHORIZATION

1. The foregoing questions are true and correct to the best of my knowledge.
2. I acknowledge and understand that I am responsible for all of the services rendered to me or my dependent family member by Liza Maniquis-Smigel, M.D., LLC.  I agree to pay promptly upon receipt of the monthly statement.
3. I hereby authorize payment of medical benefits on my behalf to be made directly to Liza Maniquis-Smigel, M.D., LLC for services rendered.
4. I voluntarily consent to have Liza Maniquis-Smigel, MD provide medical care, including diagnostic and treatment procedures deemed necessary to aid and assist in the diagnosis and treatment of myself or my dependent family member.

AGREEMENT TO RELEASE CONFIDENTIAL INFORMATION

I understant and agree that Liza Maniquis-Smigel, M.D., LLC will keep any and all information Regarding my medical condition confidential within the laws of the HIPAA Privacy Act. Written consent must be obtained from me for disclosure of my medical information to any person or entity other than my referring physician, another medical facility to which I may be referred by Liza Maniquis-Smigel, M.D., LLC, or the party(ies) obligated to pay for said services.

MEDICARE AUTHORIZATION (Medicare patients only)

PRESCRIPTION POLICY

NOTICE OF PRIVACY PRACTICE (NPP)

I have received the Notice of Privacy practice and acknowledge the opportunity to review the NPP as provided by HIPAA regulations.