FORM - 5A
TAPAN K. CHAUDHURI, MD
AUTHORIZATION FOR RELEASE OR PROTECTED HEALTH INFORMATION
Patient Name : ______________________________ SS# : _______________________ Birth Date : ___________________
Address : _____________________________________________________________      Phone # : ___________________
I, ____________________________ , hereby authorize the use of disclosure by Tapan K. Chaudhuri, MD and its Business Associates of my protected health information to the following, as described below :
  (Please print name, address, and telephone number of person)
Spouse ____________________________________________________________________________________________
Parent _____________________________________________________________________________________________
Child ______________________________________________________________________________________________
Relative ____________________________________________________________________________________________
Friend _____________________________________________________________________________________________
Other ______________________________________________________________________________________________
___________________________________________________________________________________________________
 
This release of information is for the specific purpose of discussing your billing account. Specific description of information to be disclosed :
 
  Patient Demographics Insurance Information
  Payment History Accounts Receivable Information
  Services Performed Diagnoses
  Other _______________________________  
 
I understand the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations. This authorization shall remain in effect until revoked in writing. I understand I may revoke this authorization at any time by notifying Tapan K. Chaudhuri, MD in writing and that the revocation will not take effect until the written revocation is received.
 
___________________________________________________ ______________________________
Signature of Patient or Legal Guardian Date
 
Return to : Tapan K. Chaudhuri, MD
  Attn: Billing Services Privacy Officer
  6225 Raytown Trafficway
  Raytown, MO 64133
 
FORM - 5B
I consent to treatment and the use and disclosure of my health information for treatment, healthcare operations and described in the Notice of Health Information.
 
 
_________________________________ ___________________________________
Signature of Patient or Legal
Representative
(Practice) Signature of Employee
Witness
   
_________________________________ ___________________________________
Date Notice or Version Effective Date
   
Accepted __________________________  
   
Denied ___________________________  
   
_________________________________ _______________________
Privacy/Security Officer Date
I hereby revoke/amend the consent given above as follows :
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________ ___________________________
Signature Date
 
___________________________________________
Printed name of patient
 
Address for revocation : _________________________________________________________________
Your revocation will be effective once it is received at the above address.
 
Accepted ___________________
 
Denied    ___________________
 
___________________________________ ___________________________
Privacy/Security Officer Date