Appointment request:

I have requested medical and or surgical services from Arista OB/GYN; and by checking the box below I acknowledge that I voluntarily consent to treatment by Arista OB/Gyn;. I agree to treatment by its medical personnel including any physician and/or any other designated personnel who are under their control, who may otherwise be involved in performing such treatment or procedures; to perform said treatment, evaluation, lab tests, physical exam and/or procedures. I specifically consent to receive treatment from the Physician, Physician Assistant, Certified Nurse Midwife, Nurse Practitioner or other medical personnel in the employ of, or under the control of Arista OB/Gyn;. I voluntarily consent to and authorize Arista OB/Gyn; to perform such diagnostic tests, physical exams, ultrasounds, biopsies, administration of medications, etc. and other tests as may be needed, necessary or desirable in the professional judgment of the attending physicians , Physician Assistants, Certified Nurse Midwives, Nurse practitioners, Ultrasonographers or other licensed personnel. I understand that I have the right to see or talk with the physician prior to any prescriptive drug or prescriptive device order being carried out by the Physician Assistant or other licensed midlevel provider. I am aware that the practice of medicine and surgery and obstetrics and gynecology is NOT an exact science and I acknowledge that no guarantees or assurances have been made to me as to the result of any treatment, test, diagnosis, pregnancy, surgery or outcome . Arista OB/Gyn; is sometimes involved in health care education, and I agree that unless I specifically request otherwise; at times, care, examination and treatment may be delivered by students or medical personnel in training who are under the supervision of the attending physicians. Still or motion pictures of patient care may also be used for educational purposes, unless I specifically request otherwise. Authorization for Release of Medical Information I authorize Arista OB/Gyn; to release to any insurance carrier, hospital, physician, employer, government, social service agency, or to any payor or provider of medical benefits which may or will pay for any part of my medical expenses incurred, any information pertaining to my care, whether before, during or after my treatment, for the purpose of evaluating and processing claims for my care at Arista OB/Gyn;. I further authorize Arista OB/Gyn; to disclose information regarding my care to the designated utilization review or peer review organization or committee of my insurer, employer or other payor or provider of medical benefits, and to such other parties as may be necessary to effectuate payment for my care . I authorize the release of my medical records to other physicians, hospitals, governments, ambulatory surgery centers, health departments or other institutions for the purpose of continuing care and/or transfer of my care. I acknowledge and understand that Arista OB/Gyn; may be required to submit certain reviews of the care of patients to accrediting and licensing agencies and to other such persons as may require access to the medical information or medical record. I understand that I may obtain a copy of my medical record in accordance with the policies and procedures of Arista OB/Gyn; and that I will be required to pay the charges for reproduction, if a copy of any portion of the record is requested. I understand that if the physician determines that disclosure of the medical record will be detrimental to my physical or mental health Arista OB/Gyn; may refuse to furnish the record to me. I authorize Arista OB/Gyn; to release any information acquired in the course of my examination and/treatment including, but not limited to, information related to psychiatric care, drug and alcohol abuse, sexually transmitted diseases and human immunodeficiency syndrome and complex (HIV/AIDS) confidential information. I hereby authorize and direct payment to Arista OB/Gyn; for the surgical and/or medical benefits otherwise payable to me under the terms of my insurance coverage. I understand that this assignment does not relieve me of any responsibility I may have for payment of charges not paid by my insurance company, unless otherwise provided by the terms of an agreement between the insurance company and Arista OB/Gyn;. I understand that if certification is denied then benefits may be withheld. I understand that to protect myself from unnecessary financial losses, I must review my obligations with my insurance company, utilization review program and company benefits coordinator. I hereby authorize any physician, hospital, or medical care facility to provide any and all information on my medical history and treatment to Arista OB/Gyn;. I agree that this authorization will cover all medical and/or surgical services rendered. I authorize photocopies of this form to be as valid as the original. I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND ANY QUESTIONS I HAVE ASKED HAVE BEEN ANSWERED OR EXPLAINED IN A SATISFACTORY MANNER. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ OR HAD IT READ OR EXPLAINED TO ME AND I UNDERSTAND THIS FORM AND I VOLUNTARILY CONSENT TO ALLOW Arista OB/Gyn; OR ANY PHYSICIANS DESIGNATED OR SELECTED BY IT AND ALL MEDICAL PERSONNEL UNDER THE DIRECT SUPERVISION AND CONTROL OF SUCH PHYSICIANS AND ALL OTHER PERSONNEL WHICH MAY OTHERWISE BE INVOLVED IN PERFORMING SUCH PROCEDURES, TO PERFORM THE PROCEDURES AND SERVICES DESCRIBED ABOVE OR OTHERWISE REFERRED TO HEREIN.

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We need your birth date to properly find your record. Thanks!