Patient Registration

Insurance Information

If you check any box other than “self” please indicate the name of the responsible party or subscriber:

I hereby authorize and give my consent to CIS to leave messages on my answering machine/ voicemail system for the following (including returned phone calls):

I hereby authorize and give my consent to CIS to communicate any of the Protected Health Information (PHI) to the following person(s):

Consent for Use and Disclosure of Health Information:

This is to inform you that CIS may use and disclose your health information that identifies you, and this consists of your past, present, or future physical or mental health or condition, the provision of your health care, and the past, present, or future payment for the provision of your healthcare. This health information is referred to herein as Protected Health Information (PHI)
The use and disclosure of your PHI will be to carry out treatment, payment, and healthcare operations of CIS.
For a more complete description of how CIS may use and disclose your PHI, please request a copy.
You have the right to request that we be restricted from using or disclosing your PHI in carrying our treatment, payment, or health care operations; however, we are not required to agree to you requested restrictions. If we do agree to your requested restrictions, then we will comply with your request.
You have the right to revoke this consent. This revocation must be made in writing to CIS. This revocation will be valid except to the extent that CIS has acted in reliance on this consent.

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand I am financially responsible for any balance. I also authorize CIS or insurance companies to release any information required to process my claims.

Cardiovascular Institute of the Shoals

2095 Florence Blvd. Florence, AL 35630

Consent to Release Medical Records (HIPPA Authorization)

Please list your doctors that we can request records from

T hereby authorize and request:

(The custodian of the patient's medical records) to provide a copy of the patient's Medical Records to:

Cardiovascular Institute of the Shoals

Phone: 256-766-2310

Fax: 256-768-9956

By providing this consent, I understand the following:

This consent is voluntary. My refusal to sign this form will not affect my treatment, payment, or eligibility for benefits.
The medical information to be released will not be subject to re-disclosure by CIS and it will be protected by State and/or Federal privacy rules.
I may revoke this consent at any time by notifying the above listed medical record custodians in writing, but such revocation will hav no effect on disciosures of information already made prior to the receipt of my revocation.
This consent will expire 1 year from the date set forth below.

A copy of this consent may be used in place of and with the same force and effect as the original.