I authorize Ideal Option, PLLC to communicate with and disclose to one another the following information to any Third-Party Payor (Commercial Insurance Company/Medicaid/Medicare/etc.) related to my care at Ideal Option, PLLC for the purpose of Billing and Collection.
Complete Patient Record for Billing and Collection, including progress reports, chart notes, urine drug testing results, lab tests, treatment plan, demographics, verification of funding source(s), and billing documentation.
I authorize Ideal Option, PLLC to disclose to any third-party payor all necessary information and relevant portions of my patient record for the purpose of receiving payment for services rendered.
I understand that my alcohol/drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has already been taken in reliance on it (including the provision of treatment services in reliance on a valid consent to disclose information to a third-party payer), and that in any event this consent expires 365 days after my deactivation from Ideal Option as a patient.
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I acknowledge that the information to be released was fully explained to me and that this consent is given on my own free will and that by signing I have reviewed and understand the terms of this consent. I understand that I will be provided a copy of this document at my request.