GK

Medical Marijuana Questionnaire
This information will let us know more about you.

HIPAA Privacy Authorization Form Authorization for Use or Disclosure of Protected Health Information

Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164

Authorization

  • I authorize Compassionate Care of Florida, LLC to use and disclose the protected health information described below to the physician that performs my physical exam.

Effective Period

  • This authorization for release of information covers the period of healthcare from: a.� until I issue notice of its revocation.

Extent of Authorization

  • I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).
  • This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct
  • I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
  • I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization
  • I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
* By clicking on Next you are agreeing to the websites Terms & Conditions.

Personal Information (Please enter all identifying information carefully since this information is required by the state in order to obtain a patient ID and Medical Card.)

Male Female
Yes obtain medical records
No, I will bring my records with me.
No, I don't have any medical records.
* By clicking on Next you are agreeing to the websites Terms & Conditions.

Please select one or more of the conditions that are chronic and debilitating....

PTSD
Anxiety disorder
Chronic Neck Pain
Chronic Low Back Pain
Chronic Muscle Spasms
Spinal Cord injury
Epilepsy / Seizure disorder
Multiple sclerosis
Cancer
Chronic nausea
Chronic Joint pain (Osteoarthritis, Degenerative Disk Disease, Herniated Disks, Gout, Spondylosis
Spondylolithesis, Spinal stenosis, Traumatic fracture, Vertebral Compression Fractures)
HIV /AIDS
Glaucoma
Crohns disease
Ulcerative Colitis
Migraine Headaches
Parkinson's disease
Rheumatoid arthritis
Lupus
Diabetes with peripheral neuropathy
Peripheral Neuropathy
Irritable bowel syndrome
Interstitial cystitis
Chronic pelvic pain (Adhesions, Endometriosis, Fibroids, Ovarian cysts, Pelvic Inflammatory disease, etc)
Fibromyalgia
Hepatitis C
ALS (Amyotrophic Lateral Sclerosis
Neurogenic bladder
Scleroderma
Other