New Patient Forms

I authorize the release of information including the diagnosis, records; examination rendered to me and claims information.

I do NOT authorize the release of information including the diagnosis, records; examination rendered to me and claims information.

I agree to receive messages from IDCOKC.

I hereby authorize payments directly to Infectious Diseases Consultants of Oklahoma City of the surgical and/or medical benefits. I understand that I am responsible for any portion of my bill not covered by my insurance company within the terms of its contract.

I hereby authorize release of information necessary for filing my insurance claim or filing a payment review.

Please review our notice of privacy practices carefully and save to your records. By signing, you agree that you have received a Notice of Privacy Practices from the office of David Chansolme, MD.

>Please review the patient consent information for use and disclosure of protected health information carefully. By signing, you agree you have signed the patient consent for use and disclosure of protected health information from the office of David Chansolme, MD.