I consent to entering into a client-provider relationship. I authorize Department of Health staff and their representatives to render routine health care. I understand routine health care is confidential and voluntary and may involve medical visits including obtaining medical history, assessment, examination, administration of medication, laboratory tests and / or minor procedures.I may discontinue this relationship at any time.

PART II DISCLOSURE OF INFORMATION CONSENT (treatment, payment or healthcare operations purposes only) I consent to the use and disclosure of my health information; including medical, dental, HIV/ AIDS, STD, TB, substance abuse prevention, psychiatric / psychological, and case management; for treatment, payment and health care operations.Additionally, I consent to my health information being shared in the Health Information Exchange(HIE), allowing access by participating doctors’ offices, hospitals, care coordinators, labs, radiology centers, and other health care providers through secure, electronic means.If you choose not to share your information in the HIE, you may opt out by requesting and signing an HIE Opt - Out form.

PART III MEDICARE PATIENT CERTIFICATION, AUTHORIZATION TO RELEASE, AND PAYMENT REQUEST (Only applies to Medicare Clients) As Client / Representative signed below, I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct.I authorize the above agency to release my health information to the Social Security Administration or its intermediaries / carriers for this or a related Medicare claim.I request that payment of authorized benefits be made on my behalf.I assign the benefits payable for physician's services to the above - named agency and authorize it to submit a claim to Medicare for payment.

PART IV ASSIGNMENT OF BENEFITS (Only applies to Third Party Payers) As Client/Represntative signed below, I assign to the above named agency all benefits provided under any health care plan or medical expense policy. The amount of such benefits shall not exceed the medical charges set forth by the approved fee schedule. All payments under this paragraph are to be made to above agency. I am personally reponsible for charges not covered by this assignment.

PART V COLLECTION, USE OR RELEASE OF SOCIAL SECURITY NUMBER (This notice is provided pursuant to Section 119.071(5)(a), Florida Statutes.) For health care programs, the Florida Department of Health may collect your social security number for identification and billing purposes, as authorized by subsections 119.071(5)(a)2.a.and 119.071(5)(a)6., Florida Statutes.By signing below, I consent to the collection, use or disclosure of my social security number for identification and billing purposes only.It will not be used for any other purpose.I understand that the collection of social security numbers by the Florida Department of Health is imperative for the performance of duties and responsibilities as prescribed by law.

PART VI MY SIGNATURE BELOW VERFIES THE ABOVE INFORMATION AND RECEIPT OF THE NOTICE OF PRIVACY RIGHTS

PART VII WITHDRAWAL OF CONSENT
I withdraw this consent from the given effective date