Broward Community & Family Health Centers, Inc.

The undersigned patient and/or authorized relative/legal guardian hereby consents to authorize Broward Community & Family Health Centers, Inc., its facilities or treatment centers and affiliated physicians, dentists, surgeons, and other medical personnel, to administer and perform any and all medical examinations and treatments that may now or during the course of the patient’s care be necessary or advisable and further agree to hold Broward Community & Family Health Centers, Inc., its affiliates and medical personnel, harmless for all such medical treatments.

METHOD OF PAYMENT

  1. I authorize the release of any medical information, including any HIV (AIDS), mental health and/or substance abuse test (s) and results necessary to process all health insurance claims (current and supplemental) to Medicare, Medicaid, insurance company (s), physicians (s), and/or other health care facility or health care providers to whether this facility may refer the patient. I further agree to release Broward Community & Family Health Centers, Inc. , its facilities, treatment centers, and it’s affiliated personnel from all legal responsibility and/or liability that may arise from the release of such records and waive all rights I have to preserve their confidentiality.
  2. I authorize Broward Community & Family Health Centers, Inc., its facilities or treatment centers and its affiliates, to verify my information with my employer(s) and/or inform my employer(s) in a worker’s compensation claim(s).
  3. I authorize payment of all medical benefits directly to Broward Community & Family Health Centers, Inc., or its affiliated facility treatment center as designated.

Broward Community & Family Health Centers, Inc. is a FTCA deemed facility. This is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n). For further information on our FTCA status, please contact BCFHC Corporate Office at (954) 266-2999.

Contact Us

5010 Hollywood Blvd.
Hollywood, FL 33021

Tel: (954) 266-2999
Fax: (954) 966-3320

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