Authorization for Routine Diagnostic Procedure and Treatment – I hereby consent to such diagnostic procedures and treatments including physiological, psychological and behavioral health services, which in the judgment of my healthcare provider may be considered necessary or advisable. I recognize that the Altamonte Dermatology physicians, advanced practice providers (APPs) and staff perform health care teaching and research and that my treatment and care may be observed and in some instances aided by students and residents under appropriate supervision. I consent to Altamonte Dermatology taking photographs of me in the course of and related to my treatment and I consent to the use of such photographs and my medical data for educational purposes by Altamonte Dermatology. I also hereby authorize Altamonte Dermatology to retain, preserve and use for scientific, educational or research purposes, or dispose of as they might deem fit, any specimens or tissues taken from my body.

Assignment of Benefits and Responsibilities for Payment – I hereby assign to Altamonte Dermatology payment from all third party payors with whom I have coverage or from whom benefits are or may become payable to me, for the charges of any health care services I receive for, related to, or connected with this visit or treatment by Altamonte Dermatology (past, present, or future). I agree to be personally responsible for payment of any healthcare services that are not covered by third party payors, including, but not limited to, non-covered or out-of-network services, deductibles, co-insurance, and/or co-payments. Third party payors include, but are not limited to, coverage available from: Medicare, Medicaid, Tri-care, or governmental programs; health, accident, automobile, or other insurance; worker's compensation; HMO (commercial, Medicaid, Medicare); self-insured employers; and any sponsors who may contribute payment for services.

Psychology/Psychiatry Services Records – I hereby understand and agree that my medical record containing psychiatry, psychological and behavioral health information may be available to physicians, nurses, medical assistants, students and other staff at Altamonte Dermatology, and discussion of my case may occur between a student, a resident, and his/her supervisor alone or in small groups of students or residents for whom the supervisor has responsibility.

Prescription History – I understand that performing a medication reconciliation in order to prevent adverse drug interactions and overdose is a critical component to my care. By signing this form, I authorize my provider to query and review my medication fill history including drug, dose, form, strength, prescribing provider, and pharmacy.

Use and sharing of health information – By signing below as Patient/Representative I hereby authorize Altamonte Dermatology and its physicians and APPs providing services during treatment and care, to release information from and/or copies of my medical records (including information relating to psychiatric and/or psychological care, alcohol and/or substance abuse, genetic diseases and test results, sickle cell anemia, tuberculosis, birth control, abortion, sexually transmitted diseases, and HIV/AIDS tests) and other information as may be required for my treatment and quality assurance, to secure payment for charges incurred by me or on my behalf, to any Altamonte Dermatology affiliated facility or provider, to other treating providers (including health care providers outside Altamonte Dermatology), to third party payors for which I have assigned benefits for my treatment and care, to any sponsors that Altamonte Dermatology may later obtain to contribute payment for my treatment and care, and to any and all regulatory and/or accrediting organizations as necessary for Altamonte Dermatology to maintain its licensure and accredited status as well as for participation in utilization review and Healthcare Effectiveness Data and Information Set (HEDIS) reporting to insurance companies. I also authorize release of any information to county, state or federal public health agencies, disease registries, and as required by law.

Exchange of Health Information - Altamonte Dermatology participates in the Commonwell platform, which makes health information available as needed by persons providing medical care, enabling the patient to receive more informed and better coordinated care and to avoid unnecessary duplication of tests, inconvenience and unnecessary cost. By signing below as Patient/Representative, I agree to Altamonte Dermatology exchanging my health information with other health care providers treating me. This information may include sensitive health information related to mental health conditions and treatment (including psychological and psychiatric care), sexually transmitted diseases, birth control, abortion, substance (drug and alcohol) abuse and treatment, genetic diseases and genetic test results, sickle cell anemia, tuberculosis and HIV/AIDS. I understand I am not required to consent to this exchange of health information as a condition of treatment. I understand that I can opt out of this exchange of health information or revoke my consent effective for future health information by contacting the Health Information Specialist for Altamonte Dermatology at 407-260-2606 to make that election.

Workers Compensation – I hereby authorize Altamonte Dermatology to release information from and/or copies of my medical records related to the workplace injury or illness, to the employer, workers’ compensation insurance carrier, or their attorneys.

Guarantor Agreement – By signing below as Patient/Representative, I hereby agree that all charges connected with the treatment, not covered by any insurance, sponsorship or other third party coverage I may have, are due and payable by me at the time of the visit. If the insurance information I have provided is not active at the time of service or if the services provided are not covered by my insurance plan, I will be responsible for any balance due. The charges I agree to pay are those listed in the current Billing Charge Fee Schedules unless otherwise established by an applicable agreement. I hereby acknowledge that, Altamonte Dermatology has agreed to bill my insurance or other third party carrier as a courtesy and that Altamonte Dermatology has the right to demand payment in full from me at any time prior to full payment from any third party payor. If an overdue account is referred for collections, I agree to pay the attorney's fees, court costs and/or collection agency fees associated with the collection process. I specifically waive any exemption of wages from garnishment, which might be available by law, and agree that my wages can be garnished in the event a Judgment is entered against me for collection of the charges for the services provided to me.

Lien on Third Party Liability Proceeds – If my treatment is due to an accident or injury, Altamonte Dermatology shall have a lien upon the proceeds of any cause of action, suit, claim, counterclaim, or demand accruing to me or my legal representative as a result of such accident or injury, in order to recover payment for all charges of health care services I receive for, related to, or connected with such accident or injury (past, present, or future), effective as of the date treatment was first provided. The foregoing shall be sufficient notice to me of the existence of a lien, which shall be effective whether or not it is filed in the public records. The foregoing is in addition to any lien to which Altamonte Dermatology may be entitled by law.

Agreement to Pay for Professional Component and Other Pathology Services – Some services such as laboratory and imaging are provided by third party organizations that are not affiliated with Altamonte Dermatology and I understand I may receive separate bills for these services directly from the organization providing the service, and I agree to be financially responsible for such bills.