Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Which office are you being treated in?* Toms River Freehold AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION1. I authorize Pathways Neuropsychology Associates to use and disclose my protected health information to the following:Physicians:Attorney:Other: 2. This authorization for release of information covers the period of healthcare from:Start DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920toEnd DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920**OR** all past, present & future periods 3. Extent of Authorization:Extent of Authorization I authorize the release of my complete records I authorize the release of my complete records with the EXCEPTION of the following: Exceptions Mental Health Records Alcohol/Drug Abuse Treatment Communicable Diseases Demographic Information 4. This medical information may be used, by the person I authorize, for medical treatment or consultation, billing or claims payment, or other purposes I direct. 5. I understand that I have the right to revoke this authorization, in writing, at any time and this will expire when treatment ends. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if it was obtained as a condition of insurance coverage, as the insurer has the legal right to contest a claim. 6. I understand that my treatment, payment, enrollment, or eligibility of benefits will not be conditioned on whether I sign this agreement. 7. I understand that the information used to pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal and state law. I understand that my records are protected under HIPAA State Confidentiality Regulations and cannot be disclosed without my written consent or otherwise provided for in the regulations.If patient is a minor (17 & under), both parents or guardians are required to sign this release. If the minor is 14-17 years of age their signature is also required.Patient SignatureParent/Guardian SignatureCONSENT FOR RECORDING VISITS - AUDIOPurpose and Functionality: iQ is a Scribe tool that uses artificial intelligence to summarize clinical documentation. iQ works by listening to the conversation during your appointment and then summarizing the session into clinical note suggestions to assist your clinician in reviewing and documenting your health record. iQ does not make any decisions regarding consumer care nor does it interact directly with you. Benefits for Consumers: iQ benefits both the clinician and consumers by improving the accuracy of clinical documentation, reducing documentation interruptions during appointments, and allowing the clinician to focus on the consumer. Privacy and Security: Privacy and Security is a top priority. iQ complies with HIPAA and the Assistant Secretary of Technology Policy/ Office of the National Coordinator regulations for Predictive Decision Support Interventions. iQ is an AI Scribe tool that is available as part of electronic health record and is not a separate tool or system limiting the risk of data exposure. iQ session audio capture and transcripts are deleted following the session. No consumer data is used to train the AI system without additional consumer consent.Patient SignatureLegal Representative SignaturePATIENT BILL OF RIGHTSAs your right upon reading and signing this form, it is understood that you have access to all privacy practices and your Patient Bill of Rights with Pathways Neuropsychology Associates. You may access the Patient Bill of Rights at length, anytime, on our official website www.pathwaysneuropsychology.com.Patient SignatureParent/Guardian SignatureHIPAA COMPLIANCE PATIENT CONSENT FORMYou have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice reserves the right to change the privacy policy as allowed by law. The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The practice may condition receipt of treatment upon execution of this consent. May we phone, email, or send a text to you to confirm appointments?* YES NO May we leave a message on your answering machine at home or on your cell phone?* YES NO May we discuss your medical condition with any member of your family?* YES NO If YES, please name the members allowed:By signing below, I certify that I have read and understand the above statements regarding release of protected health information, the AI recording of my visits, my patient rights, and my HIPAA rights. I also certify that to the best of my knowledge, all information I entered on these forms is true and correct.Patient SignatureDateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Legal Guardian SignatureDateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Legal Guardian SignatureDateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Legal Representative SignatureDateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Δ
