CAPITOL ORTHOPAEDICS &
REHABILITATION, LLC
Use and disclosure of protected health
information
PATIENT ACKNOWLEDGEMENT AND CONSENT
FORM
Acknowledgment of
notification
The educational pamphlet entitled "Notice of Privacy Practices" provides information about how Capitol Orthopaedics and Rehabilitation, LLC may use and disclose
protected health information about you, and is compliant with the requirements of the Health Insurance Portability and Accountability Act of 1996 "HIPAA".
Our Notice of Privacy Practices states that we reserve the right to change the terms described.  Should this happen, you will be notified on your next visit to our office.
You have the right to request restrictions on how your protected health information may be used or disclosed for treatment, payment, or health care operations.  We are
not required to agree to your restrictions; but if we do, we are bound by our agreement with you.
By signing below, you acknowledge receipt of our Notice of Privacy
Practices.
Patient's Signature                                                                                                      
         Date
Consent for Use and Disclosure of
Information
By signing below, 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, except where we have already made disclosures in
trust on your prior consent.
I request that payment of authorized Medicare/Insurance carrier benefits be made on my behalf to Capitol Orthopaedics and
Rehabilitation, LLC for any services furnished to me by that physician or supplier.  I authorized any holder of medical information
about me to release to the Centers for Medicare/Medicaid Services and its agent and/or any other insurance carriers for which I
have coverage any information needed to determine these benefits were the benefits payable for related services.  I agree to
provide all referral and treatment plan(s) as required by my insurance carrier(s).  All co-pays must be paid at the time of service in
accordance with the contracted insurance carrier agreements.
Patient's Signature                                                                                          
         Date
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6000 Executive Blvd. #510 | Rockville, MD 20852 | (301) 770-7900