CONSENT TO USE AND DISCLOSE HEALTH INFORMATION
This consent authorizes Central Bucks Family Practice to use and disclose health information about you for treatment, payment and health care operations.
Explanation of rights – Read this before signing the consent
Central Bucks Family Practice has a Notice of Privacy Practices that describes how we use and disclose protected health information about you and how you can access your protected health information. You may review our current notice prior to signing this consent. We reserve the right to change our Notice of Privacy Practices and to make the terms of any change effective for all protected health information that we maintain. You may obtain a revised notice by submitting a written request to our Privacy Officer.
You have the right to request that we restrict how your protected health information is used or disclosed to carry out treatment, payment or health care operations. We are not required to agree to any requested restrictions. However, if we agree to a requested restriction, we are bound by the restriction.
You have the right to revoke this consent, except to the extent that we have taken action in reliance on the consent. To revoke this consent, you must submit a written revocation to our Privacy Officer.
Current contact information for our Privacy Officer:
Practice Name: Central Bucks Family Practice
Attention: Privacy Officer
Address: 252 West Swamp Road, Suite 41, Doylestown, PA 18901
I have read and understand the above Explanation of Rights and have been provided the opportunity to review the Notice of Privacy Practices for Central Bucks Family Practice prior to signing this consent. I authorize Central Bucks Family Practice to use and disclose health information to the parties I provided for treatment, payment and health care operations in accordance with its’ Notice of Privacy Practices.
I acknowledge that the information and contacts I provided today is accurate.
I hereby authorize Central Bucks Family Practice to release any information acquired in the course of my examination or treatment for insurance claims, and authorize payment directly to Central Bucks Family Practice of the surgical and/or medical benefits, in any, otherwise payable to me for their services. I understand I am financially responsible for all charges not covered by this authorizations and guarantee payment of this account.