I authorize West Orange Nephrology, LLC to perform procedures and treatment including administration of medicine along with other surgical and medical procedures the may be necessary. I authorize the release of any medical information necessary to process a claim and hereby assign benefits payable to West Orange Nephrology, LLC in the event of another health insurance becoming primary over my health insurance. To further provide continuity of care, I authorize the release of medical information to other specialty physicians. Furthermore, any services not covered by my insurance will become my responsibility to full payment services rendered by West Orange Nephrology, LLC.

The office of West Orange Nephrology will not call and leave a message unless you have authorized to do so. This includes reminders of appointments, lab results, chart information and ext. Please state where, when, and who you are comfortable sharing information with.

I consent to the use or disclosure of my protected health information by West Orange Nephrology for the purpose of diagnosing or providing treatment to me, obtaining payment for my healthcare bills or to conduct healthcare operations of WEST ORANGE NEPHROLOGY, LLC. I understand that diagnoses or treatment of me by West Orange Nephrologists may be conditioned upon my consent as evidence by my signature on this document. I understand that I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of his practice. WEST ORANGE NEPHROLOGY, LLC is not required to agree on the restrictions that I may request, the restriction is binding on WEST ORANGE NEPHROLOGY, LLC. I have the right to revoke this consent in writing, at any time, except to the extent that WEST ORANGE NEPHROLOGY, LLC has taken action in reliance on this consent. My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer, or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand that I have the right to review WEST ORANGE NEPHROLOGY LLC’s Notice of Privacy Practices prior to signing this document. The WEST ORANGE NEPHROLOGY LLC’s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of bills or in the performance of health care operations of WEST ORANGE NEPHROLOGY LLC. The Notice of Privacy Practices for WEST ORANGE NEPHROLOGY LLC is also provided 301 S. West Crown Point Road, Suite 120, Winter Garden, FL 34787. The Notice of Privacy Practices also describes my rights and the WEST ORANGE NEPHROLOGY LLC’s duties with respect to my protected health information. I understand that I need to call WEST ORANGE NEPHROLOGY LLC’S office 24 hours in advance to reschedule. We would like to accommodate other patients on our waiting list. WEST ORANGE NEPHRLOGY LLC’s reserves the right to charge $50.00 for no show appointments and same day cancellations. WEST ORANGE NEPHROLOGY LLC reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy to be sent in the mail or asking for one at the time of my next appointment.