I authorize The Genesis Therapy Center to use and disclose the health and medical information of for the purposes of Treatment, Payment and Health Care Operations. **Treatment (includes activities performed by a health care provider, nurse, office staff, and other types of health care professionals providing care to you, coordinating or managing your care with third parties, and consultations with and between other health care providers. This consent includes treatment provided by any therapist who covers our practice by telephone as the on-call therapist).*Payment (includes activities involved in determining your eligibility for health plan coverage, billing and receiving payment for your health benefit claims, and utilization management activities which may include review of health care services for medical necessity, justification of charges, and pre-certification and pre-authorization.*Health Care Operations (includes the necessary administrative and business functions of our office).
We encourage you to review the Genesis "Privacy Notice" for additional information about the use s and disclosures of information described in this Consent prior to signing this consent. Please verify that you have receive d a copy of your Privacy Notice by placing your initials here: Initials
Because we have reserved the right to change our privacy practices in accordance with the law, the terms contained in the notice may change also. A summary of the Notice will be posted in our office indicating the effective date of the Notice in the upper right hand corner. We will offer you a copy of the Notice on your first visit to us after the effective date of the then current notice. We will also provide you with a copy of the Notice upon your request.As more fully explained in the Notice, you have the right to request restrictions on how we use and disclose your protected health information for treatment, payment, and health care operations purposes. We are not required to agree with your request. If we do agree, we are required to comply with your request unless the information is needed to provide you emergency treatment. Other therapists who provide call coverage for our office are required to use and disclose your Protected Health Information consistent with the Notice.I understand that I have the right to revoke this Consent provided that I do so in writing, except to the extent that the Genesis Therapy Center has already used or disclosed the information in reliance on this Consent.Signature of Client Signature* Signature of Person Authorized by Law Signature Date Date