Authorization to release healthcare information and payment guarantee

I authorize the release of my medical records, treatment and advice, and specific health information to:

• TREATING PHYSICIANS on staff at Vitality Urgent Care and their staff, agents of another healthcare facility if direct transfer to another facility is required, and to my primary care physician or any referred consultants for follow up care.
• AN EMPLOYER who requests services. This may include your personal medical history, physical, laboratory and diagnostic tests, and drug screenings (including the presence of drugs, alcohol or marijuana).
• INSURANCE COMPANY or other third-party payer and their agents as well as any review organization or government agency for the purpose of determining eligibility and available benefits, obtaining payment for services provided, and insuring government compliance.

I, the undersigned, authorize the Vitality Urgent Care to submit claims to my insurance company. I authorize to use and disclosure of my personal information for the purposes of diagnosing or providing treatment to me, obtaining payments for my care, or for the purposes of conducting the health care operations of the practice. I also authorize Vitality Urgent Care to release any information required in the process of application for financial coverage for the services rendered. This authorization provides that the practice may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agents. If it is the case that my insurance company utilizes a managed care company, my therapist may need to discuss my treatment with a case manager. I understand that my confidentiality will be compromised in such a case. I realize that his/her doing so is a necessity in his effort to secure ongoing care.