Consent To Change Personal Health Information Preference printable pdf download

Consent To Change Personal Health Information Preference

Date: ______

Consent to Change Personal Health Information Preference

Please use this form if you want to change your previous decision about Medicare sharing

your personal health information with Michael Mignoli, MD regarding care you receive

from other doctors or healthcare providers.

You can also call 1-800 MEDICARE (1-800-633-4227) instead of completing this form.

TTY users should call 1-877-486-2048. Call 1-800-MEDICARE and say that you want

to change your previous decision about Medicare sharing your personal health

information with Michael Mignoli, MD, or that you want to talk about the

Comprehensive Primary Care Initiative.

To help us give you the right care in the right place at the right time, Medicare can share

certain personal health information with Michael Mignoli, MD about care you receive

from other doctors or health care providers. This information will include things like

visits to the doctor or hospital, medical conditions, and prescriptions you’ve had in the

past and moving forward. Having this information will help Michael Mignoli, MD give

you high-quality care, because Michael Mignoli, MD will have the most up-to-date

information about your health.

Your privacy is very important to us, and you control the use of your personal

health information.

This form should be used if you have previously informed Medicare that you do not want

Medicare to share with Michael Mignoli, MD your personal health information regarding

care you have received from other doctors or healthcare providers. You would have done

this in one of the following ways:

• Returning a completed and signed “Declining to Share Personal Health

Information” form to Michael Mignoli, MD, either in person or via mail to the

address listed in section D below.

• Calling 1-800 MEDICARE (1-800-633-4227 (TTY: 1-877-486-2048) and telling

Medicare NOT to share your personal health information with [Name of Practice].

If you are not sure whether your personal health information regarding care you receive

from other doctors or providers is currently being shared with Michael Mignoli, MD

please call 1-800 MEDICARE (1-800-633-4227).

Consent To Change Personal Health Information Preference