Our notice of privacy practices provides information about how we may use or disclose protected health information.
The notice contains a patient's rights section describing your rights under the law. You ascertain by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for use of the information for treatment, payment, or healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However such a revocation will not retroactive.
By signing this form, I understand that:
__Protected information may be disclosed or used for treatment, payment, or healthcare operation.
__The practice reserves the right to change the privacy policy as allowed by law
__The patient has the right to restrict the use of the information, but the practice does not have to agree to those restrictions
__The patient has a right to revoke this consent in writing at any time and all full disclosures will the cease
__The practice may condition receipt of treatment upon execution of this consent.
May we phone you to confirm appointments? YES NO
May we leave a message on your answering machine at home or on your cell? YES NO
May we leave a message at your employment? YES NO
May we discuss your medical condition with any member of your family? YES NO
If yes, please name the members allowed: ___________
This consent was signed by: _____(signature)
_____(print name)
________(date)
Witness:______ Date:____
