I hereby give my consent for Bob Dalsania DDS to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Bob Dalsania DDS describes such uses and disclosures more completely.)
I have received a copy of the Notice of Privacy Practices and have the right to review it prior to signing this consent. Bob Dalsania DDS reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Mindy Chipman, Privacy Officer, 839 Highway 51 S, Covington, TN 38019.
With this consent, Bob Dalsania DDS may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointments reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Bob Dalsania DDS may mail to my home or other alternative location, any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential”.
With this consent, Bob Dalsania DDS may disclose to the pharmacy of my choice any PHI needed by the pharmacy in order to fill prescriptions to assist both Bob Dalsania DDS and the pharmacy in my treatment. This consent serves as sufficient written notice to the pharmacy of my choosing that I consent to their use of the PHI provided to fill prescriptions prior to me giving my written consent at that particular pharmacy, which will be provided at the time of prescription pick-up. I have agreed to do so to expedite my treatment by the pharmacy and Bob Dalsania DDS.
With this consent, Bob Dalsania DDS may disclose to any hospital or specialist to whom I need a referral to my PHI, that which is minimally necessary, to assist both Bob Dalsania DDS and the other covered entity in my treatment. This consent serves as sufficient written notice to the other covered entity, to whom I am being referred, that I consent to their use of the PHI provided to schedule appointments for specialty consultation and/or laboratory or diagnostic testing. Use of the provided PHI may be done without me having provided written consent to the other
covered entity so that my treatment may be provided in a more expeditious manner.
I have the right to request that Bob Dalsania DDS restrict how he uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Bob Dalsania DDS to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do sign this consent or later revoke it, Bob Dalsania DDS may decline to provide treatment to me.
A copied signature, in the case of facsimile transmission, is considered as valid as an original signature.