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About Us
Application For Employment
Employment Opportunities
Executive Leadership/Administration
Mission Statement and Vision Statement
Our Philosophy of Integrated Care
Services & Specialties
PATIENT PORTAL
Clinical Associates Services
After Hours Care Center
Ambulatory Surgery Center (ASC)
Procedure Prep Instructions & Forms
Colonoscopy Forms - Authorization and Informed Consent
Colonoscopy Forms - Consent to Anesthesia
Colonoscopy Forms - Billing Procedures for our ASC
Colonoscopy Forms - HIPPA Consent Form
Colonoscopy Forms - Advanced Directives
Endoscopy - Authorization and Informed Consent
Endoscopy - Anesthesia Consent
Endoscopy - Billing Procedures for our ASC
Endoscopy - HIPAA Consent Form
Endoscopy - Advanced Directives
Diabetes Resources and Education
Diabetes Educational Classes
Laboratory & Radiology Services
New - Cardiac PET Imaging
Nuclear Medicine
Puva
Travel Clinic
Clinical Associates Specialties
Audiology
Cardiology
Dermatology
Endocrinology
Family Practice
Gastroenterology
Geriatrics
Internal Medicine
Optometry and Ophthalmology
Otolaryngology (ENT)
Podiatry
Urology
Locations
Clinical Associates at Cockeysville
Clinical Associates at Glyndon
Clinical Associates at Reisterstown
Clinical Associates at the Rotunda
Clinical Associates at Towson
Clinical Associates at Woodholme
Medical Providers
New Patient Info
How We May Use and Disclose Medical Information About You
Our Pledge Regarding Medical Information
Privacy Complaints or Concerns
Special Situations
Your Rights Regarding Medical Information About You
Participating Insurances
Contact Us & Billing Information
Search
Submit
About Us
Application For Employment
Employment Opportunities
Executive Leadership/Administration
Mission Statement and Vision Statement
Our Philosophy of Integrated Care
Services & Specialties
PATIENT PORTAL
Clinical Associates Services
After Hours Care Center
Ambulatory Surgery Center (ASC)
Procedure Prep Instructions & Forms
Colonoscopy Forms - Authorization and Informed Consent
Colonoscopy Forms - Consent to Anesthesia
Colonoscopy Forms - Billing Procedures for our ASC
Colonoscopy Forms - HIPPA Consent Form
Colonoscopy Forms - Advanced Directives
Endoscopy - Authorization and Informed Consent
Endoscopy - Anesthesia Consent
Endoscopy - Billing Procedures for our ASC
Endoscopy - HIPAA Consent Form
Endoscopy - Advanced Directives
Diabetes Resources and Education
Diabetes Educational Classes
Laboratory & Radiology Services
New - Cardiac PET Imaging
Nuclear Medicine
Puva
Travel Clinic
Clinical Associates Specialties
Audiology
Cardiology
Dermatology
Endocrinology
Family Practice
Gastroenterology
Geriatrics
Internal Medicine
Optometry and Ophthalmology
Otolaryngology (ENT)
Podiatry
Urology
Locations
Clinical Associates at Cockeysville
Clinical Associates at Glyndon
Clinical Associates at Reisterstown
Clinical Associates at the Rotunda
Clinical Associates at Towson
Clinical Associates at Woodholme
Medical Providers
New Patient Info
How We May Use and Disclose Medical Information About You
Our Pledge Regarding Medical Information
Privacy Complaints or Concerns
Special Situations
Your Rights Regarding Medical Information About You
Participating Insurances
Contact Us & Billing Information
Telehealth Services
Health Alert - COVID-19
Message from Gary A. Manko, MD, FACP, President of Clinical Associates
Notice - Billing Telehealth Services
Telehealth Visits
ASC Procedure Instructions & Forms
Endoscopy - HIPAA Consent Form
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting the Ambulatory Surgery Center at Clinical Associates. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice/ASC provided this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The Patient Understands That:
Protected health information may be disclosed or used for treatment, payment, or health care operations.
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
The Practice reserves the right to restrict the uses of their information but the Practice does not have to agree to the restrictions.
The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
The Practice may condition receipt of treatment upon execution of this Consent.
The Consent was signed by:
Patient Name:
Patient Signature:
(name in corresponding box will act as signature)
Date:
Signature of Representative/Relationship:
(name in corresponding box will act as signature)
Date:
Witness Signature:
(name in corresponding box will act as signature)
Date:
In this Section
Services & Specialties
PATIENT PORTAL
Clinical Associates Services
After Hours Care Center
Ambulatory Surgery Center (ASC)
Procedure Prep Instructions & Forms
Colonoscopy Forms - Authorization and Informed Consent
Colonoscopy Forms - Consent to Anesthesia
Colonoscopy Forms - Billing Procedures for our ASC
Colonoscopy Forms - HIPPA Consent Form
Colonoscopy Forms - Advanced Directives
Endoscopy - Authorization and Informed Consent
Endoscopy - Anesthesia Consent
Endoscopy - Billing Procedures for our ASC
Endoscopy - HIPAA Consent Form
Endoscopy - Advanced Directives
Diabetes Resources and Education
Laboratory & Radiology Services
New - Cardiac PET Imaging
Nuclear Medicine
Puva
Travel Clinic
Clinical Associates Specialties
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