Susan Kreher, M.D., F.A.C.C.
Masih Uddin, M.D.
PATIENT INFORMATION

Last Name
First Name
MI

Street Address

City
State
ZIP
Home Phone
Work Phone
Employer Name
Employer Address
 
/ /
Date of Birth		 / /
Social Security Number    		  
Sex

SPOUSE/PARENT INFORMATION

Last Name
First Name
MI
/ /
Date of Birth		 / /
Social Security Number    		  
Employer Name Phone

INSURANCE INFORMATION

Insurance Name
Subscriber's Name

Policy Number
Group Number

Secondary Insurance
Subscriber's Name

Policy Number
Group Number

OTHER
Referring Physician Phone
Emergency Contact Name Phone


This form is to confirm your authorization to use or disclose your protected health information for a special purpose.

I give my authorization to use or disclose my protected information as described below. I give this authorization voluntarily.

I hereby authorize Dr. Masih Uddin, P.C. and/or Classic City Cardiology, P.C. and its affiliates to release any medical information necessary to process any and all claims filed by them. I understand that I am financially responsible for all charges incurred, regardless of what insurance coverage I may currently have.

I hereby authorize payment directly to Dr. Masih Uddin, P.C. and/or Classic City Cardiology, P.C. and its affiliates for all services performed.

I hereby authorize any hospital and/or physician to disclose and release to Dr. Masih Uddin, P.C. and /or Classic City Cardiology, P.C. any and all information obtained in connection with my physical condition, surgical and /or medical treatment with the understanding that any information obtained will be treated as confidential.

I hereby authorize Dr. Masih Uddin, P.C. and/or Classic City Cardiology, P.C. to release or disclose my protected health information to any physician treating or consulting me in connection with my physical condition, surgical and/or medical treatment with the understanding that any information disclosed will be treated as confidential.

I hereby authorize Dr. Masih Uddin, P.C. and/or Classic City Cardiology, P.C. to release or disclose my protected health information to my spouse and or children.

___________________________________________________
Signature
______________________________
Date

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