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Disclosure of your Social Security Number (“SSN”) is
required of you in order for patient services. Federal law mandates a
social security number is required to obtain benefits under Medicare and
Medicaid (42 USC, Section 1320b-7(1)). For commercial insurance, there is
no statute or authority that requires that you disclose your SSN for this
purpose. Failure to provide your SSN, however, may result in us not filing
claims for your patient care because commercial insurance requires a SSN.
Further disclosure of your SSN is governed by the Public Information Act
(Chapter 552 of the Texas Government Code) and other applicable law.
NOTICE ABOUT INFORMATION LAWS
AND PRACTICES
With few exceptions, you are entitled on your request to
be informed about the information The University of Texas Health Science
Center at San Antonio collects about you. Under Sections 552.021 and
552.023 of the Texas Government Code, you are entitled to receive and
review the information. Under Section 559.004 of the Texas Government Code,
you are entitled to have The University of Texas Health Science Center at
San Antonio correct information about you that is held by The University of
Texas Health Science Center at San Antonio and is incorrect, in accordance
with the procedures set forth in The University of Texas System Business
Procedures Memorandum 32. The information that The University of Texas
Health Science Center at San Antonio collects will be retained and
maintained as required by Texas records retention laws (Section 441.180 et
seq. of the Texas Government Code) and rules. Different types of
information are kept for different periods of time.
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You may send any requests to Harry S.
Lynch Jr., MBA, CPA
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By mail to: 7703 Floyd Curl Drive, San
Antonio, TX 78229-3900
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By e-mail to: Lynch@UTHSCSA.edu
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By fax to: (210) 567-7027
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In person at: Medical School Building,
Room 426
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CONSENT FOR RELEASE
I consent for the release of my social security number for the
stated purpose above.
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Printed Name:
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Signature:
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Date:
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