Form Consent For Use And Disclosure Of Health Information printable pdf download

CONSENT FOR USE AND DISCLOSURE OF

HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT

Name:

Address:

Telephone:

E-mail:

Patient Number:

Social Security Number:

SECTION B: TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out

treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent.

Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make

of your protected health information, and of other important matters about your protected health information. A copy of our Notice

accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we

will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health

information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Contact Person:

Telephone:

Fax:

E-mail:

Address:

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to

the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this

Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this

Consent.

SIGNATURE

I, ______________________________________________, have had full opportunity to read and consider the contents of this Consent

form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and

disclosure of my protected health information to carry out treatment, payment activities and heath care operations.

Signature:

Date:

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative’s Name:

Relationship to Patient:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

Include completed Consent in the patient’s chart.

Form Consent For Use And Disclosure Of Health Information