Acknowledgement of Notice of Privacy PRACTICES & CANCELLATION POLICY
I have reviewed the Notice of Privacy Practices of NorthStar Surgery Specialists, P.A., which explains in plain language how my protected health information (PHI) will be used and disclosed, my individual rights, and the practice’s legal duties with respect to my PHI. I understand that I am entitled to receive a copy of this information upon request.
I also acknowledge the following cancellation/no show policy: New patients that no show to a scheduled appointment are subject to a $50 no show charge. Established/post-operative patients are subject to a cancellation/reschedule/no show charge of $50 if a 24 hour notice is not given, 7 day notice must be given to cancel/reschedule surgery, if 7 day notice is not given, you are subject to a $250 cancellation fee.
Release of Medical Records
I am requesting that the medical information be transferred to Vineet Choudhry MD.
I understand that the information in my or my child’s health record may include information relating to STD, AIDS, or HIV. It may also include information about behavioural or mental health services, and treatment for alcohol and drug abuse.