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Patient Consent for Treatment and Use and Disclosure of Protected Health Information

I, or my parent or guardian, have completed this form and consent that it is correct to the best of my knowledge. I authorize The MediCentral to render necessary evaluation and treatment to myself/child/ward.

I consent to the Health Service and HIPPA Privacy Notice. The practice will bill my insurance company for its services, if applicable.

I consent to all communication, including but not limited to communication about my medical condition and advice from my health care providers by the following means; Voice, text and email.

I hereby give my consent for The MediCentral (the Practice) to use and disclose my child's protected health information (PHI) to perform treatment, payment and health care operations (TPO).

With this consent, the Practice may call me or email me to my home or other alternative location and leave a message by voice, email or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and anything pertaining to my clinical care, including laboratory test results

With this consent, the Practice may mail to my home or other alternative location any items that assist the practice in performing TPO, such as appointment reminder cards, patient statements and anything pertaining to my child's clinical care as long as they are marked "Personal and Confidential."

By signing this form, I am consenting to allow the Practice to use and disclose my PHI to carry out TPO.

I may reboke my consent in writing except to the extent that the Practice has already made disclosures upon my prior consent. If I do not sign this consent, or later revoke it, the Practice may decline to provide treatment to my child.

This consent is valid for all visits from date of signature until the end of the school year 2023.

HIPAA Privacy Rule of Patient Authorization Agreement

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

a basis for planning my care and treatment;
a means of communication among the health professionals who may contribute to my health care;

a source of information for applying my diagnosis and surgical information to my bill;

a means by which a third-party payer can verify that services billed were actually provided;

a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice prior to signing this authorization.

I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

I authorize The MediCentral to send school notes directly to the school nurse.

 

Privacy Rule of Patient Consent Agreement

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:

I have the right to review this Practice’s Notice of Information practices prior to signing this consent; that this Practice reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I’ve provided, if requested;

I have the right to object to the use of my health information for directory purposes;

I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare  operations, and that this Practice is not required by law to agree to the restrictions requested;

I may revoke this consent in writing at any time, except to the extent that this Practice has already taken action in reliance thereon.

This authorization is valid from date of signature until the end of the school year 2023.