Please read the following privacy practice form and print out for signature and date. You will need to bring this completed form along with the other required Patient Registration forms to your first office visit. If you have any questions regarding the following information, we will gladly review and discuss any details or concerns at your visit. Thank you.
NOTICE AND ACKNOWLEDGMENT OF RECEIPT OF PRIVACY PRACTICES
- Patient Consent To Treat
I, the undersigned patient, consent to such treatment procedures as are deemed necessary by the provider, including those which are in addition to or different from those initially contemplated, and which are deemed necessary or advisable by the provider in the course of treatment.
- Patient Consent for Use and Disclosure of Protected Health Information (PHI)
I, the undersigned patient, give my consent to the provider entity and its agents to use or disclose my protected health information (PHI) to carry out treatment, payment, or health care operations. These individuals and entities can release, use or disclose my PHI to other health care personnel including, but not limited to, physicians, certified registered nurse anesthetists, anesthesia assistants, nursing staff, nurse practitioners, physician assistants, child life specialists, physical therapists, respiratory therapists, X-ray personnel, audiologists, students in each of the above disciplines, and other such entities or persons as are deemed related to treatment, or payment, and health care operations, as determined in the sole discretion of the provider, his/her practice group, and their respective agents.
- Permission to Release Medical Records to Providers
If another provider who is involved with my treatment, payment, or health care operations relating to me requests my medical records, I consent to the release of my entire medical record maintained by the provider to those other providers.
- Permission to Release Billing Information Over the Telephone
I agree, as part of this consent for payment operation, that the provider, its group, and their billing personnel, billing agents, or management company can disclose billing information to any person who calls the provider with a billing question after the provider inquires as to the identity of the calling person and the calling person provides my correct social security number or health plan number.
- Permission to Call and Leave Voice Mail Messages
I agree that the provider or its agents or representatives may call and leave a voice mail message at my home or other number I provide them regarding medical appointments, billing or payment issues, or other information related to treatment, payment or health care operations.
- Permission to Discuss Protected Health Information With Third Persons
I agree that the provider may discuss my PHI with any person who accompanies me to a visit or procedure or is present with me when the provider is present. The provider may rightly assume that if another person is with me, I have no objection to disclosure of my PHI to that person. I also agree that the provider may discuss my PHI with any person who identifies him or herself as active in my mental, physical, emotional, or spiritual care, including, but not limited to family, friends, clergy, and patient advocates. I also agree that the provider, his/her practice group, and their agents may disclose my PHI to employers who arrange and pay, directly or indirectly, for my medical treatment.
- Permission to Discuss Protected Health Information Regarding Minors
I agree that the provider, his/her practice group, and their agents may discuss my child’s PHI with the person accompanying the child. I agree that the provider may discuss PHI with both natural parents and stepparents. I acknowledge that state law may grant my child certain privacy rights regarding the child’s PHI, and that I have no right to receive this information.
- Permission to Discuss Protected Health Information With Public Agencies
I agree the provider, his/her practice group, and their agents may, upon request by the following entities, disclose my PHI to public health agencies, law enforcement, and the FDA.
- Acknowledgment of Receipt of Notice of Privacy Practices
I acknowledge that I have received this Notice of Privacy Practices which sets forth this provider’s privacy practices and my rights regarding privacy of my PHI.