Forms

New OB Patient Forms

Notice of HIPAA Privacy Practices

Patient Privacy Practices Agreement

    Mark E. Richey, M.D., P.C. made the following good faith efforts to obtain the above-referenced individual’s written acknowledgement of receipt of the Notice of Privacy Practices: (Please identify the efforts that were made to obtain the individual’s written acknowledgement, including the reasons (if known) why the written acknowledgement was not obtained.)

    Patient Registration Form

      Patient Information

      Spouse/Parent Information

      Emergency Contact Information

      Insurance Information

      I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, PPO plans and other health plans to Dr. Mark E. Richey. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information needed to secure the payment.

      Private insurance is a contract between you and your insurance company. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual information as necessary.

        Patient Information

        Spouse/Parent Information

        Emergency Contact Information

        Insurance Information

        I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, PPO plans and other health plans to Dr. Mark E. Richey. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information needed to secure the payment.

        Private insurance is a contract between you and your insurance company. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual information as necessary.

        New Patient Agreement

          Dr. Mark Richey offers general medical, and specialty gynecological and obstetrical services for patients. We require certain information from each patient in order to begin your care. The additionally provided forms need to be completed in order for us to get you started and maintain your records as our patient.

          • Patient Registration Form & Patient Agreement **
          • Healthcare Portability & Accountability Act (HIPAA) Notice of Privacy Practices Acknowledgement**
          • State or Federally Issued Identification Card (Please provide at each visit)
          • Copy of Insurance Identification Card (annually or as insurance coverage changes)
          • Medical Genetics Questionnaire (for new OB patients) *
          • New Patient & Pre-Physical Exam Questionnaires (for all new patients) *
          • Choice of Laboratory (if you/your insurance prefers a specific lab other than Quest Lab)
          • Review of Systems (Clinical consideration worksheet you may complete at each visit)

          ** To be completed every three (3) years unless the forms change with new requirements

          * To be completed by new patients


          PAYMENT FOR SERVICES

          Each patient is responsible for the payment of their medical services. We gladly bill healthcare payers as a courtesy to our patients and need a copy of your current insurance ID card. If your healthcare insurance payer does not cover particular medical services, you are welcome to make self pay arrangements at the usual and customary pricing.

          DISCOUNTS FOR IMMEDIATE PAYMENT

          If you would like to pay at the time service or prior to services being rendered, we can offer you a 10% discount. Due to Dr. Richey’s participation in federally funded programs, discounts after the time of services cannot be offered. We will not post duplicative discounts for both patient payments and insurance contract discounts.

          NO SHOW FEES

          If you are not able to keep your scheduled appointment you need to contact our front desk one (1) business day in advance. Failure to notify the front desk and confirm your cancellation with staff may result in a no show fee. No show fees are required to be paid prior to scheduling future appointments.

          ALASKA MEDICAID RECIPIENTS

          Only a limited number of new Medicaid patients are accepted each month. Patients seen with Medicaid coverage are required to provide proof of eligibility and co-pays at the time of service. If a patient is admitted for service on the premise that they do not have Medicaid and later obtain retroactive primary or secondary coverage, the patient may be liable to pay for all services provided prior to providing proof of current or prospective Medicaid and meeting the practices’ service limits.

          All patients that fail to attend scheduled appointments and are charges a “no-show” fee are responsible to pay the no-show fee prior to scheduling additional appointments. Medicaid does not cover “no-show” fees, as is specifically described in the Alaska Administrative Code (AAC) 7 AAC 105.110. Noncovered services (8) for missed appointments; however, the provider may charge the recipient.

          REFERRALS FOR PERINATOLOGY MEDICAL SERVICES

          When a patient has a need to see a specialist for a service that medically justifies it, Dr. Mark E. Richey will use his best professional opinion and expertise to send you to the most qualified practitioner he is aware of to meet your medical need. Dr. Richey provides specialty care in gynecology & obstetrics. If a patient may benefit from the services of a board certified perinatologist, patients may be referred to Alaska Perinatology Associates for those medical needs associated with pregnancy. All patients have the right to choose their practitioners and patient requests will be observed. Please consult Dr. Richey on your preferences at the time of referral.

          REFERRALS FOR OTHER MEDICAL SERVICES

          Certain practitioner services may need a physician referral for healthcare payer reimbursement. If you believe you would benefit from a referral to a practitioner that requires a physician referral, please consult with Dr. Richey about this at the time of your visit.

          STERILIZATION SERVICES

          Many healthcare payers, including federally funded payers may require that we have written authorization and/or consent to provide sterilization services. We may need your cooperation to complete forms for these services.

          QUALITY ASSURANCE & RESOLUTION

          Should you have a concern or experience a situation that requires the direct attention of Dr. Richey, please contact our practice either by phone or in writing. Our staff will interact with you and Dr. Richey to reach a resolution of any identified situation where our quality of service has been compromised or may need to be reviewed. We use such situations to alert us to improvements we can make to better serve all our patients.

          ASSIGNMENT OF BENEFITS

          My signature on this agreement is my written authorization for Mark Richey, MD, PC to submit claims to my identified healthcare payer and receive direct payment for deposit of funds paid on my behalf under my current healthcare coverage. This is a direct assignment of my rights and benefits under my current insurance policy for payment of my medical services. I also authorize the release of any information pertinent to my care to my insurance, adjuster or attorney involved in the care and payment of my medical services. This provider has my permission to submit claims or complaints on my behalf to the State of Alaska Division of Insurance.

          BILLING INFORMATION

          Our practice uses Sage Consulting Incorporated, a professional billing service, to process your claims to healthcare payers and to arrange payment of patient balances. We have all the required agreements in place to insure that your protected health information is safe and remains confidential. If you have inquiries about your healthcare claims, monthly statements or if you have additional billing information, you may reach our billing agent at:

          FOR BILLING INQUIRES AND MAKING PAYMENTS

          CALL OR FAX

          (907) 272-4443 Phone

          (907) 272-2262 Fax


          PAYMENT & PAYMENT PLANS

          All patients are responsible for any and all charges not paid for or discounted under contract by healthcare insurance payers (Medicare, Medicaid, Private Health Insurance Carriers, Worker’s Compensations, etc.). By signing this patient agreement, you are acknowledging that you understand this condition of service and commit to reimbursing Mark Richey MD, PC, in a timely manner for the services we provide to you, our valued patient.

          We accept cash, checks, and credit or debit cards (VISA, Mastercard, American Express, Discover Card). We offer pre-payment discounts and recurring monthly payment arrangements for patient balances. We are willing to make reasonable payment arrangements to keep your account current. Please contact our Billing Office at (907) 272-4443.

          We offer patients the opportunity to make payments on balances over the period of three (3) months following the issuance of the first patient statement. Exceptions can be made to extend the repayment period upon review and approval. Failure to pay on a patient account as agreed is a basis for an account to be assigned to collections for bad debt recovery.

          INTEREST CHARGES ON PATIENT BALANCES

          Our practice charges interest on unpaid account balances. Following payment/denial reply on your claims from your healthcare insurance payer, we will bill you for the balance of the unpaid portion of your visit. Interest will begin to accrue on unpaid balance 30 days AFTER we have sent you the 1st statement of the amount that is due. We charge interest based upon the percentages approved by Alaska Statute. You may contact our billing agent for the current rate of interest.

          COLLECTION OF PAST DUE ACCOUNTS

          We communicate with our patients to resolve past due accounts in all cases. If we cannot reach a patient by phone following the return of undeliverable mail or if a patient payment agreement cannot be honored and we are not communicated with to resolve account balances, we may be forced to use the services of a professional collection agency. Once an account is placed with our contracted collection agency, under our contract with them, we cannot take the account back. Please let us know when or if your patient contact information changes so that we can always reach you to discuss any past due accounts.

          RELEASE OF PATIENT CLINICAL RECORDS

          All release of medical records requires a signed and dated Release of Information (ROI) form with a current date (within prior 90 days). Please allow two (2) business days to process records requests.

          PATIENT STATEMENT OF AGREEMENT

          This patient agreement and the terms within it are effective for three (3) years from the date of my signature or until the agreement is revised.

          My signature below signifies that I have read and understand this patient agreement for Mark Richey, MD, PC to provide me medical services. I understand and agree to the terms in this patient agreement and intend on complying with them to the best of my ability. I also understand that if I fail to follow the terms of this agreement, I could be cancelled from future services.

          Assignment of Insurance Benefits

            This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this received on my account when made out to me.

            I authorize Dr. Mark E. Richey to make a deposit into the account of Dr. Mark E. Richey on my behalf.

            A photocopy of this Assignment shall be considered as effective and valid as the original.

            I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

            I authorize Dr. Mark E. Richey to initiate a complaint to the Insurance Commissioner on my behalf.

            Patient Choice of Laboratory Form

              Please indicate the laboratory service of your choice. We will default any labs or specimens collected in our office to Quest Diagnostics, unless otherwise specified. We will forward any specimens that require laboratory processing to the laboratory of your choice. Laboratory results will be placed on record for physician reference at the designated hospital lab and will also be retained in your patient file here at Dr. Mark Richey’s office.

              When making your choice, you may want to consider:

              • Your health plan coverage for services at any preferred hospitals
              • Convenience of laboratory location and hours of operation
              • Which hospital you are most likely to receive services at if you need or anticipate hospital care services (as your records will be available at that location as well)

              If after completing this form, if you decide you would like to change your laboratory preference, simply complete a new form at your next visit.

              We can fax your orders or results to the laboratory of your choice, as well as provide you with written orders to take with you for your laboratory services.

              Laboratory services will be billed by the facility or company performing the tests. Dr. Mark Richey is not responsible for submitting claims, or billing you or your healthcare insurance payer for laboratory services. You are financially responsible for all laboratory services. Please bring a copy of your insurance card with you to your initial registration at the laboratory.

              Your signature below is confirmation that you have selected a preferred laboratory and understand the terms of laboratory referral services described above.

              Patient Review of Systems Form

                Please take a moment to complete the following questions. It will help us keep current on very important health issues affecting you and provide the most efficient use of your time with the doctor.

                Patient Medical Genetics Questions Form

                  Having a baby is a special event. Once a baby is born, families take certain precautions to ensure the baby’s health and safety. The unborn child deserves similar care. While most babies are born healthy, some babies can be born with a birth defect or develop a significant health problem after birth. Many of these problems occur despite the best prenatal care; however, some birth defects can be prevented, or at least detected, before birth with appropriate screening. This questionnaire is designed to identify certain factors in your family or medical history that may have an impact on your pregnancy outcome. It is important to answer all of the questions as completely as possible. You may need to discuss some of the questions with other family members to obtain additional information.

                  Past Pregnancy History

                  Family History

                  Your Family

                  Baby's Father's Family

                  Testing

                  Current Pregnancy

                  New GYN Patient Forms

                  Notice of HIPAA Privacy Practices

                  Patient Privacy Practices Agreement

                    Mark E. Richey, M.D., P.C. made the following good faith efforts to obtain the above-referenced individual’s written acknowledgement of receipt of the Notice of Privacy Practices: (Please identify the efforts that were made to obtain the individual’s written acknowledgement, including the reasons (if known) why the written acknowledgement was not obtained.)

                    Patient Registration Form

                      Patient Information

                      Spouse/Parent Information

                      Emergency Contact Information

                      Insurance Information

                      I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, PPO plans and other health plans to Dr. Mark E. Richey. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information needed to secure the payment.

                      Private insurance is a contract between you and your insurance company. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual information as necessary.

                      New Patient Agreement

                        Dr. Mark Richey offers general medical, and specialty gynecological and obstetrical services for patients. We require certain information from each patient in order to begin your care. The additionally provided forms need to be completed in order for us to get you started and maintain your records as our patient.

                        • Patient Registration Form & Patient Agreement **
                        • Healthcare Portability & Accountability Act (HIPAA) Notice of Privacy Practices Acknowledgement**
                        • State or Federally Issued Identification Card (Please provide at each visit)
                        • Copy of Insurance Identification Card (annually or as insurance coverage changes)
                        • Medical Genetics Questionnaire (for new OB patients) *
                        • New Patient & Pre-Physical Exam Questionnaires (for all new patients) *
                        • Choice of Laboratory (if you/your insurance prefers a specific lab other than Quest Lab)
                        • Review of Systems (Clinical consideration worksheet you may complete at each visit)

                        ** To be completed every three (3) years unless the forms change with new requirements

                        * To be completed by new patients


                        PAYMENT FOR SERVICES

                        Each patient is responsible for the payment of their medical services. We gladly bill healthcare payers as a courtesy to our patients and need a copy of your current insurance ID card. If your healthcare insurance payer does not cover particular medical services, you are welcome to make self pay arrangements at the usual and customary pricing.

                        DISCOUNTS FOR IMMEDIATE PAYMENT

                        If you would like to pay at the time service or prior to services being rendered, we can offer you a 10% discount. Due to Dr. Richey’s participation in federally funded programs, discounts after the time of services cannot be offered. We will not post duplicative discounts for both patient payments and insurance contract discounts.

                        NO SHOW FEES

                        If you are not able to keep your scheduled appointment you need to contact our front desk one (1) business day in advance. Failure to notify the front desk and confirm your cancellation with staff may result in a no show fee. No show fees are required to be paid prior to scheduling future appointments.

                        ALASKA MEDICAID RECIPIENTS

                        Only a limited number of new Medicaid patients are accepted each month. Patients seen with Medicaid coverage are required to provide proof of eligibility and co-pays at the time of service. If a patient is admitted for service on the premise that they do not have Medicaid and later obtain retroactive primary or secondary coverage, the patient may be liable to pay for all services provided prior to providing proof of current or prospective Medicaid and meeting the practices’ service limits.

                        All patients that fail to attend scheduled appointments and are charges a “no-show” fee are responsible to pay the no-show fee prior to scheduling additional appointments. Medicaid does not cover “no-show” fees, as is specifically described in the Alaska Administrative Code (AAC) 7 AAC 105.110. Noncovered services (8) for missed appointments; however, the provider may charge the recipient.

                        REFERRALS FOR PERINATOLOGY MEDICAL SERVICES

                        When a patient has a need to see a specialist for a service that medically justifies it, Dr. Mark E. Richey will use his best professional opinion and expertise to send you to the most qualified practitioner he is aware of to meet your medical need. Dr. Richey provides specialty care in gynecology & obstetrics. If a patient may benefit from the services of a board certified perinatologist, patients may be referred to Alaska Perinatology Associates for those medical needs associated with pregnancy. All patients have the right to choose their practitioners and patient requests will be observed. Please consult Dr. Richey on your preferences at the time of referral.

                        REFERRALS FOR OTHER MEDICAL SERVICES

                        Certain practitioner services may need a physician referral for healthcare payer reimbursement. If you believe you would benefit from a referral to a practitioner that requires a physician referral, please consult with Dr. Richey about this at the time of your visit.

                        STERILIZATION SERVICES

                        Many healthcare payers, including federally funded payers may require that we have written authorization and/or consent to provide sterilization services. We may need your cooperation to complete forms for these services.

                        QUALITY ASSURANCE & RESOLUTION

                        Should you have a concern or experience a situation that requires the direct attention of Dr. Richey, please contact our practice either by phone or in writing. Our staff will interact with you and Dr. Richey to reach a resolution of any identified situation where our quality of service has been compromised or may need to be reviewed. We use such situations to alert us to improvements we can make to better serve all our patients.

                        ASSIGNMENT OF BENEFITS

                        My signature on this agreement is my written authorization for Mark Richey, MD, PC to submit claims to my identified healthcare payer and receive direct payment for deposit of funds paid on my behalf under my current healthcare coverage. This is a direct assignment of my rights and benefits under my current insurance policy for payment of my medical services. I also authorize the release of any information pertinent to my care to my insurance, adjuster or attorney involved in the care and payment of my medical services. This provider has my permission to submit claims or complaints on my behalf to the State of Alaska Division of Insurance.

                        BILLING INFORMATION

                        Our practice uses Sage Consulting Incorporated, a professional billing service, to process your claims to healthcare payers and to arrange payment of patient balances. We have all the required agreements in place to insure that your protected health information is safe and remains confidential. If you have inquiries about your healthcare claims, monthly statements or if you have additional billing information, you may reach our billing agent at:

                        FOR BILLING INQUIRES AND MAKING PAYMENTS

                        CALL OR FAX

                        (907) 272-4443 Phone

                        (907) 272-2262 Fax


                        PAYMENT & PAYMENT PLANS

                        All patients are responsible for any and all charges not paid for or discounted under contract by healthcare insurance payers (Medicare, Medicaid, Private Health Insurance Carriers, Worker’s Compensations, etc.). By signing this patient agreement, you are acknowledging that you understand this condition of service and commit to reimbursing Mark Richey MD, PC, in a timely manner for the services we provide to you, our valued patient.

                        We accept cash, checks, and credit or debit cards (VISA, Mastercard, American Express, Discover Card). We offer pre-payment discounts and recurring monthly payment arrangements for patient balances. We are willing to make reasonable payment arrangements to keep your account current. Please contact our Billing Office at (907) 272-4443.

                        We offer patients the opportunity to make payments on balances over the period of three (3) months following the issuance of the first patient statement. Exceptions can be made to extend the repayment period upon review and approval. Failure to pay on a patient account as agreed is a basis for an account to be assigned to collections for bad debt recovery.

                        INTEREST CHARGES ON PATIENT BALANCES

                        Our practice charges interest on unpaid account balances. Following payment/denial reply on your claims from your healthcare insurance payer, we will bill you for the balance of the unpaid portion of your visit. Interest will begin to accrue on unpaid balance 30 days AFTER we have sent you the 1st statement of the amount that is due. We charge interest based upon the percentages approved by Alaska Statute. You may contact our billing agent for the current rate of interest.

                        COLLECTION OF PAST DUE ACCOUNTS

                        We communicate with our patients to resolve past due accounts in all cases. If we cannot reach a patient by phone following the return of undeliverable mail or if a patient payment agreement cannot be honored and we are not communicated with to resolve account balances, we may be forced to use the services of a professional collection agency. Once an account is placed with our contracted collection agency, under our contract with them, we cannot take the account back. Please let us know when or if your patient contact information changes so that we can always reach you to discuss any past due accounts.

                        RELEASE OF PATIENT CLINICAL RECORDS

                        All release of medical records requires a signed and dated Release of Information (ROI) form with a current date (within prior 90 days). Please allow two (2) business days to process records requests.

                        PATIENT STATEMENT OF AGREEMENT

                        This patient agreement and the terms within it are effective for three (3) years from the date of my signature or until the agreement is revised.

                        My signature below signifies that I have read and understand this patient agreement for Mark Richey, MD, PC to provide me medical services. I understand and agree to the terms in this patient agreement and intend on complying with them to the best of my ability. I also understand that if I fail to follow the terms of this agreement, I could be cancelled from future services.

                        Assignment of Insurance Benefits

                          This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this received on my account when made out to me.

                          I authorize Dr. Mark E. Richey to make a deposit into the account of Dr. Mark E. Richey on my behalf.

                          A photocopy of this Assignment shall be considered as effective and valid as the original.

                          I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

                          I authorize Dr. Mark E. Richey to initiate a complaint to the Insurance Commissioner on my behalf.

                          Patient Choice of Laboratory Form

                            Please indicate the laboratory service of your choice. We will default any labs or specimens collected in our office to Quest Diagnostics, unless otherwise specified. We will forward any specimens that require laboratory processing to the laboratory of your choice. Laboratory results will be placed on record for physician reference at the designated hospital lab and will also be retained in your patient file here at Dr. Mark Richey’s office.

                            When making your choice, you may want to consider:

                            • Your health plan coverage for services at any preferred hospitals
                            • Convenience of laboratory location and hours of operation
                            • Which hospital you are most likely to receive services at if you need or anticipate hospital care services (as your records will be available at that location as well)

                            If after completing this form, if you decide you would like to change your laboratory preference, simply complete a new form at your next visit.

                            We can fax your orders or results to the laboratory of your choice, as well as provide you with written orders to take with you for your laboratory services.

                            Laboratory services will be billed by the facility or company performing the tests. Dr. Mark Richey is not responsible for submitting claims, or billing you or your healthcare insurance payer for laboratory services. You are financially responsible for all laboratory services. Please bring a copy of your insurance card with you to your initial registration at the laboratory.

                            Your signature below is confirmation that you have selected a preferred laboratory and understand the terms of laboratory referral services described above.

                            Patient Review of Systems Form

                              Please take a moment to complete the following questions. It will help us keep current on very important health issues affecting you and provide the most efficient use of your time with the doctor.

                              Gynecology Patient Questions Form

                                Past Medical and Family History

                                Surgeries/Hospitalization/Major Injury/Illness

                                Health Maintenance

                                Medications

                                Allergies

                                Obstetrical History

                                Gynecological History

                                Social History

                                1. The purpose of this letter is to explain the reason for and proper method of somethings that your doctors staff will do to help you during this visit. During any typical visit, you may be asked very personal questions and then undergo even more personal physical examinations. Our desire is that you better understand these procedures as you have your examination.
                                2. When you come into our office, you do not have to surrender your rights of privacy and personal security. You may remain in control of what you do and what can be done to you. What does happen is that you and the health care providers enter into a partnership where you work together to assure the best health of the patient. The health care providers are responsible for making sure that you understand as much as possible about every procedure that takes place. Also, it is the policy of this office that during any portion of the physical examination a chaperon will be provided. Finally, if at any time during an examination or treatment you do not understand what is happening you have the right and responsibility to ask for more information. Below are described some of the parts of the physical examination which will be performed during your visit.
                                3. Breast (Both sexes): The breast tissue and the underlying structures are examined visually and by touch for any abnormalities that you may need treatment. Because the tissue in and around the breast can be affected by a variety of medical conditions, it is sometimes necessary to examine the chest and breasts even when your main visit is not the breast. The examination may be very brief or very detailed, depending in the findings and condition that is being investigated. Also, you may be asked mto sit or lie in different positions so that the provider can see subtle changes in the structure. However, as stated above you should be a good understanding of each procedure and its intent during the examination.
                                4. Genitalis (male): The penis, scrotum, and testicles can be viewed or examined to investigate a variety of conditions. The inguinal canal, a passage for several structures in the groin, is usually examined by pressing a gloved finger up from below on either side of the groin. Because each of these structures have many nerve fibers, these examinations may be uncomfortable.
                                5. Genitalia (female): The female genitalia are examined visually, by gloved hands, and usually with medical instruments. As with other organs, it may be necessary to examine the genitalia, even though the primary concern is not directly related to those structures. For example, if the provider is investigating the possibility of appendicitis, he/she may feel the area of the appendix with a finger inserted into the vagina. This is because less muscle is there to interfere with the examination of the abdominal contents the female genitalia is rich with nerve fibers, and these examinations, properly performed, may be uncomfortable.
                                6. Rectal (Both sexes): A gloved finger is inserted into the rectum to see if there are any abnormal structures there or in the pelvis. In the male, a firm rubbery organ called the prostate is felt. During the examination of a woman, internal organs are felt between fingers simultaneously in the vagina and the rectum. After the rectal exam, it is common to test any substance on the glove to see whether there is any abnormal bleeding in the rectum.
                                7. This has been a brief description of some very common medical examinations performed in order to better treat you, our patient. If you have any questions please do not hesitate to ask your health care provider.

                                I have read and understand all of the above. I am aware, that if I have any questions during or after my visit, I can ask the provider or anyone of the staff for further information.

                                Medical Releases

                                Realease of Medical Information to Dr. Richey

                                  I, (name of patient) , authorize (hospital/doctor name) to use and/or disclose my health information as identified below to: Mark E. Richey, M.D., 1200 Airport Heights Drive Suite 205, Anchorage AK 99508, Fax (907) 272-2262 Phone (907) 272-4443

                                  Except to the extent that action has already been taken in reliance upon this authorization, I understand that I may revoke this authorization at any time by giving written notice to (identify the person/entity to whom written notice of revocation must be given). Unless revoked earlier, this authorization will expire 180 days from the date of signing or upon (insert applicable date or event of expiration).

                                  I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment or eligibility for benefits. I may inspect or copy any information to be used or disclosed under this authorization.

                                  I also understand that, if the person or entity receiving this information is not a health care provider orhealth plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing my health information under other applicable state or federal laws and regulations.

                                  I further understand that the person(s) I am authorizing to use or disclose my information may receive compensation (either directly or indirectly) for doing so.

                                  (A copy of this signed form will be provided to the individual and/or the individual’s legal representative.)

                                  Release of Medical Information to Another Doctor

                                    I, (name of patient), authorize Mark E. Richey, M.D., P.C. to use and/or disclose my health information as identified below to (name and address of recipient).

                                    Except to the extent that action has already been taken in reliance upon this authorization, I understand that I may revoke this authorization at any time by giving written notice to (identify the person/entity to whom written notice of revocation must be given). Unless revoked earlier, this authorization will expire 180 days from the date of signing or upon (insert applicable date or event of expiration).

                                    I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment or eligibility for benefits. I may inspect or copy any information to be used or disclosed under this authorization.

                                    I also understand that, if the person or entity receiving this information is not a health care provider orhealth plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing my health information under other applicable state or federal laws and regulations.

                                    I further understand that the person(s) I am authorizing to use or disclose my information may receive compensation (either directly or indirectly) for doing so.

                                    (A copy of this signed form will be provided to the individual and/or the individual’s legal representative.)