Privacy Policy/Rx Consent

Acknowledgment receipt of Notice of Privacy Practices

I acknowledge that I have been offered access to the Clinic Notice of Privacy Practices available on the Glacier Medical Associates website. I understand that the Notice of Privacy Practice describes how Clinic may disclose and use my protected health information.
Patient Name
Date of Birth

MonthDayYear
Date
Initials
If not signed, state reason and efforts made to have acknowledgment signed.
Consent to Obtain External Rx History
I hereby authorize Glacier Medical Associates to review my external prescription history
Intials if Authorizing
I DO NOT authorize this access:
Name if not Authorizing
Today's Date

MonthDayYear
Date
Authorization to Disclose Protected Health Information:
This information may be given to and used by the following individual(s) or organization(s). I hereby request and authorize you to release information TO:
Name(s):
Relationship to Patient
Phone:
Name(s):
Relationship to Patient
Phone:
I authorize the use or disclosure of my health information as described below. Information to be released:
Verbal discussion regarding care, conditions or financial obligations.
All Records of treatment from
MonthDayYear
Date
to

MonthDayYear
Date
Entire (Complete Record)Medication RecordAllergy ListOperative ReportHistory & Physical ReportPhysician’s OrdersX-ray ReportsLab ResultsConsultation ReportProgress NotesDrug/Alcohol InformationPsychiatry InformationImmunization RecordHIV ResultsOther
- I understand that the information in my health record may include information relating to sexually transmitted disease, behavioral or mental health services, and treatment for alcohol and drug abuse.
- I understand there will be a charge for copying records that will be paid prior to receiving my health record.
- I understand that the above-listed item or information in Clinic's possession may have been generated by Clinic or by any other source and may be released to the above listed individual or clinic.
- I understand that if the person or entity that receives the information is not a healthcare provider or a health plan covered by federal privacy regulations the information described above may be re-disclosed and no longer protected by these regulations.
- I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I understand that I may inspect or copy the information to be used or disclosed, as provided in the federal privacy regulations. If I have questions, I can contact Clinic's Privacy/Security Officer.
Unless otherwise revoked, this authorization will expire on the following date, event, or condition:*
- I understand that I may revoke this authorization in writing at any time by contacting Clinic’s Privacy Officer.
- I understand that this revocation does not apply to information that has already been released in response to this authorization.
- Failure to sign this authorization:
I certify that I have read and understand this authorization, and that a copy of the signed document has been offered to me.
Signature of Patient or Legal Guardian*

Clear
Name of Patient or Legal Guardian*
Todays Date*

MonthDayYear
Date
I revoke (cancel) this Authorization to Disclose Health Information previously signed on

MonthDayYear
Date
Cancellation Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

Consent to Obtain External Rx History

Authorization to Disclose Protected Health Information: