Privacy Consent- For the use and Disclosure of Protected Health Information
This consent is required by Health Insurance Portability and Accountability Act of 1996 to inform you of your rights for privacy with respect to your health care information.
I hereby give my consent to Dr. David R Beckman use and disclose my protected health information for the purpose of treatment, payment, and operations of my health care and the practice.
I, with my signature, authorize this family Practitioner and any employee working under the direction of this physician, to provide medical care for me, or to this patient for which I am legal guardian. This medical care may include assessment of my condition, management, treatment, and supportive care and services related to my needs and conditions. This may include (but not limited to ) evaluation of medical condition, medical management, procedures, diagnostic testing, therapeutic care, coordination of care with surgeon, hospital employees, and other medical specialists, home health care, counseling, the prescribing of drugs or other services required for you care. This may include photographs and other images to help with treatment planning at outcome assessment. This consent includes contact and discussion with other health care professionals, specialists, hospital personal, and therapists for your care and treatment.
Consent related to the Privacy Notice:
I have had a chance to review and Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change, and I may obtain these revised notices by contacting the practice by phone and writing. I understand I have the right to request how my protected health information (PHI) has been disclosed. I also have the right to restrict how this information is disclosed, but this practice is not required to agree to my restrictions. If it does agree to my restrictions on (PHI) use, it is bound by that agreement.
- I understand that this practice may refuse my services if I refuse to sign this consent. I may revoke this
consent at any time, but the practice may refuse further services at that time. If I revoke this consent, the revocation does not take effect until the practice receives it.