If you are human, leave this field blank.
Full Name *
Mailing Address *
As required by the Health Insurance Portability and Accountability Act, Heartland Women's Healthcare may not use or disclose your protected health information without your authorization except as provided in our Notice of Privacy Practices.
, understand that my health information may be protected by the Federal rules for Privacy of Individually Identifiable Health Information and/or state laws. I understand that my health information may be subject to re-disclosure by the recipient and that if the organization or person authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by the Federal privacy regulations. I understand it is the policy of Heartland Women's Healthcare that all my appointments are confirmed one working day prior to my office visit. If no one is home, a message will be left of my answering machine/voicemail with the time of my scheduled appointment. I understand this confirmation process cannot be waived or declined by myself or any individual. I understand it is a policy of Heartland Women's Healthcare that all patients who are pregnant be tested for sexually transmitted diseases including HIV and/or AIDS to safeguard the health of all unborn infants and the staff at Heartland Women's Healthcare and Labor and Delivery in the hospital and I authorize all testing at this time. I understand that my records may contain information regarding my mental health, substance use or dependency, sexuality, and also may contain confidential HIV/AIDS related information. I further understand that by signing below, I am authorizing the release or exchange of these records for the purpose of treatment, and to my insurance for benefit management and claims administration, legal processes and subpoenas, mandated treatment referral, and/or to release physical records as requested by myself or my legal representative. I understand I do not have to sign this authorization. I understand I may inspect or copy the protected health information to be disclosed by Heartland Women's Healthcare. I also understand that if, by my refusal to sign, I am preventing the billing of insurance, payment of charges, and/or endangering the life of an unborn child or a member of the Heartland Women's Healthcare office or hospital staff, non-emergency treatment may be refused. If you refuse to sign this consent form, we will not be able to treat you. Except to the extent action has already been taken in confidence on this authorization, I can, at any time, revoke this authorization by submitting a written notice to the office of Heartland Women’s Healthcare, 3408 Office Park Drive, Marion, IL 62959. Unless revoked, this authorization will expire one year from today on the following date:
Relationship Photo ID *
Drivers License, Passport, Ect.
Authorization For Release
I understand that I may alter or revoke, in writing, this authorization at any time. I further understand that any such alteration/revocation does not apply to any previously authorized use or disclosures of my health information, which have already been enacted in trust on this authorization.
I acknowledge, by my signature; I comprehend and understand the full scope of this authorization including any and all restrictions and/or permissions relegated within. This authorization will expire on year from the date of my signature.
Social Security Number
Email Address *
Primary Insurance Card Holder's Name
Social Security Number
Secondary Insurance Card Holder's Name
Social Security Number Emergency/Alternate Contact
I am required to present with current and complete insurance information & cards at each visit. If I present without this information I will be required to reschedule or pay at the time of service until valid insurance information is provided. Timely Filing Limitations for all insurance companies are applicable. If I do not provide Heartland Women's Healthcare with correct insurance information and the timely filing deadline passes, due to my failure to provide this information, or if my insurance company applies my services to a deductible, co-insurance, co-payment, or considers the services as non-covered, I accept total financial responsibility for all related charges, attorney fees, and/or collection agency fees incurred in the process of recouping my payment.
Authorization for Disclosure of Protected Health Information to Patient Portal
E-mail address that patient portal message will be sent to:
• I understand that my health care and the payment of my health care will not be affected if I do not sign this form.
• I understand that I MAY REFUSE TO SIGN THIS AUTHORIZATION. I also understand that Heartland Women’s Healthcare shall not refuse to treat me if I refuse to sign this authorization.
• Heartland Women’s Healthcare is not responsible for a breach of this information if the patient using the portal is using a computer workstation or device that could be compromised.
• I understand that this authorization MAY BE REVOKED in writing and delivered to Heartland Women’s Healthcare 3408 Office Park Dr. Marion, Illinois 62959 at any time requesting that my account be inactivated.
By clicking Submit you agree the above information is correct and agree that all signatures are E-Signatures.