QPC New Patient - Page 8

Quick Primary Care

HIPAA Notice - Page 8 of 9

New Patient Info (Continued...)

HIPAA Notice of Privacy Practices

My signature on this document acknowledges that I have received Quick Primary Care, PA's HIPAA Notice of Privacy Practices.

LIFETIME AUTHORIZATION

Insurance Assignment and Authorization to Release Information

RELEASE OF INFORMATION

I authorize the physician and Quick Primary Care, PA to release medical records and information to insurance carriers, government agencies, and other parties as needed for payment of claims and documentation of diagnosis and treatment.

PHYSICIAN INSURANCE ASSIGNMENT

I authorize payment of medical benefits directly to the physician and Quick Primary Care, PA for services rendered.

MEDICARE/MEDICAID

I certify that the information provided is accurate for Medicare/Medicaid claims and assign benefits to the physician and Quick Primary Care, PA as permitted by law.

CONSENT FOR TREATMENT

CONSENT FOR TREATMENT — I, the below named patient, hereby give my consent for treatment to all physicians associated with Quick Primary Care, PA.

AUTHORIZATION

PERMIT A COPY OF THIS AUTHORIZATION AND ASSIGNMENTS TO BE USED IN PLACE OF THE ORIGINAL WHICH IS ON FILE AT THE PHYSICIAN'S OFFICE. The assignment will remain in effect until revoked by me in writing.

Consent

CONSENT TO DISCUSS MEDICAL CONDITIONS OR RELEASE RECORDS: I, the below named patient, do hereby authorize Quick Primary Care, PA to discuss my medical conditions with, or release my medical records to the below named person(s):

Authorized Person 1

Authorized Person 2

Authorized Person 3

Signature