Notice of Privacy Practice/clinics

I acknowledge that I am provided a copy of the Notice of Privacy Practice through the Patient Portal, which describes the ways in which the practice/clinic may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. I understand that this information may be disclosed electronically by the Provider and/or the Provider's business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the Notice of Privacy Practice.

Disclosures to Friends and/or Family Members

DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER OR STAFF MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM? I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings, appointments, and care decisions to the family members listed below:

Include Full Name, Relationship to Patient, contact number and Further Instruction.

Patient/Representative may revoke or modify this specific authorization and that revocation or modification must be in writing.

Communications about My Healthcare

Release of Information

I hereby permit practice/clinic and the physicians or other health professionals involved in my care to release healthcare information for purposes of treatment, payment, or healthcare operations.

Healthcare information may be released to any person or entity liable for payment on the Patient’s behalf to verify coverage or payment questions, or for any other purpose related to benefit payment. Healthcare information may also be released to my employer’s designee when the services delivered are related to a claim under worker’s compensation.

If I am covered by Medicaid or Medicare, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. This information may include, without limitation, history and physical, emergency records, laboratory reports, operative reports, physician progress notes, nurse’s progress notes, consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary.

Federal and State laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractor in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, generic information, chemical dependency conditions, and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIDS.

Please review to ensure the details are correct before completion.