I understand that the initial assessments does NOT guarantee that you will be approved for Medical Marijuana, low THC marijuana, or any similar medical product. your content here.
CONSENT FOR RELEASE OF MEDICAL INFORMATION
I respectfully authorize and request that you release copies of my medical records to: Aysev LLC.
I authorize release of information of my medical record: I understand that this information shall be
in effect for 180 days following the date of signature. However, I understand that this authorization
may be revoked at any time by giving oral or written notice to the medical office. A photocopy of
this authorization shall constitute a valid authorization. Should my case require review by a
governing agency or another medical profession actively involved in my care to make a final
determination, it is with my consent that a copy of these records will be submitted to the agency
or medical profession for this review.
We will do our best to be on time, we can only ask the same of you. We generally wont charge a fee for
changing appointment, we get it, things happen, however - if we see a pattern where appointments are
constantly being changed and/or missed we may need to institute individual patient fees. We will not
charge someone with out letting them know before.
We attempt to contact you/your designated other to remind you of your up-coming appointment; however,
it is the responsibility of the patient to arrive for their appointment on time.
Just like you can't go into a supermarket and ask to purchase food and ask them to pay them another
time. Fees, Co-pays and forward balances are due on the day of service.
- If an account is not paid in full within 90 days, a 25% collection processing fee will be added to
the outstanding balance and will be turned over to a collection company for further processing.
- No additional appointments will be made for delinquent accounts until they are brought current.
Checks returned for any reason will be assessed a $40.00 service fee in addition to the amount of
the check. NSF checks must be redeemed with certified funds and checks will no longer be
permitted as payment.
Medical Marijuana Consent Form
A qualified physician may not delegate the responsibility of obtaining written informed consent to
another person. The qualified patient or the patient’s parent or legal guardian if the patient is a
minor must initial each section of this consent form to indicate that the physician explained the
information and, along with the qualified physician, must sign and date the informed consent
b. The approval and oversight status of marijuana by the Food and Drug Administration
c. The potential for addiction
d. The potential effect that marijuana may have on a patient’s coordination, motor skills, and
cognition, including a warning against operating heavy machinery, operating a motor vehicle, or
engaging in activities that require a person to be alert or respond quickly.
e. The potential side effects of medical marijuana use.
g. The risks, benefits, and drug interactions of marijuana
h. The current state of research on the efficacy of marijuana to treat the qualifying conditions set
forth in this section.
There does not appear to be good-quality primary literature that reported on cannabis or cannabinoids as
effective treatments for AIDS wasting syndrome.
Patient Rights Regarding Medical Records *All requests to inspect, copy, amend, restrict, or share health
information must be made in writing on the proper forms which will be provided upon request. All changes
to preferred forms of communication must also be made in writing. You have the following rights
regarding health information we maintain about you: Right to Inspect and Copy: You have the right to
inspect and copy health information that may be used to make decisions about your care. Usually, this
includes health and billing records. If you request a copy of the information, we may charge a fee for the
costs of copying, mailing, or other supplies and services associated with your request. We may deny your
request to inspect and copy in certain very limited circumstances. If you are denied access to health
information, you may request that the denial be reviewed. This review will be conducted by another
licensed health care professional chosen by our practice. The person conducting the review will not be
the person who denied your request. This practice will comply with the outcome of the review. Right to
Amend: If you believe that health information we have about you is incorrect or incomplete, you may ask
us to amend the information. We may deny your request for an amendment if it is not in writing or does
not include a reason for the request. In addition, we may deny your request if you ask us to amend
information that: • Was not created by us, unless the person or entity that created the information is no
longer available to make the amendment • Is not part of the health information kept by or for our practice •
Is not part of the information that you would be permitted to inspect and copy • Is accurate and complete
Any amendment we make to your health information will be disclosed to those with whom we disclose
information as previously specified. Right to an Accounting of Disclosures: You have the right to request a
list of the disclosures of your health information we have made, except for uses and disclosures for
treatment, payment, and health care operations, as previously described. Right to Request Restrictions:
You have the right to request a restriction or limitation on the health information we use or disclose about
you for treatment, payment, or health care operations. We are not required to agree to your request for
restrictions if it is not feasible for us to ensure our compliance or believe it will negatively affect the care
we provide you. Right to Request Confidential Communications: You have the right to request that we
communicate with you about health matters in a certain way or at a certain location. Right to a Paper
Copy of This Notice: You have the right to obtain a paper copy of this notice at any time. To obtain a
copy, please request it from any staff member. Changes to This Notice We reserve the right to change
this notice and apply it to any past, present, or future health information we have about you. We will post
a copy of the most current notice in our facility with the effective date on the first page. You may request a
copy of our most current notice at any time. Complaints If you believe your privacy rights have been
violated, you may file a complaint with us or with the Secretary of the Department of Health and Human
Services. You will not be penalized for filing a complaint. Other Uses of Health Information Other uses
and disclosures of health information not covered by this notice or the laws that apply to us will be made
only with your written permission.