Adult Consent to disclose

Name

First NameLast Name

Date*

Date

This office is required by Federal Regulations to inform our patients about the use of their health information under the Health Information Portability and Accountability Act or HIPAA.

I understand that as a part of my health care, Poole and Thomas Pediatrics originates and maintains paper records describing my health history, symptoms, examinations, test results, diagnosis, treatments, and any plans for future care or treatment. I understand that this is information serves as:

A basis for planning my care and treatment.
A means of communication among health professionals who contribute to my care.
A source of information for applying my diagnosis and treatment information to my bill.
A means by which a third party can verify the services billed to me took place.

I understand and have been provided access to a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. This notice is located on our website ptpediatrics.com and is located in paper form at the check-in window of our office. I understand that I have the following rights and privileges:

The right to review the Notice of Privacy Practices prior to signing this consent, allowing treatment, or making payment for services rendered and the right to a paper copy of the Notice of Privacy Practices.
The right to object to the use of my health information for directory purposes.
The right to request confidential communications.

I AUTHORIZE POOLE AND THOMAS PEDIATRICS AND ITS STAFF TO DISCUSS MY MEDICAL INFORMATION AS FOLLOWS

For Financial Purposes: I allow my parent(s) to access my diagnosis and treatment information and to discuss my account.
I allow my immunization records to be released by fax, email or mail to: GuardiansSchool Self

For Financial Purposes: I allow my parent(s) to access my diagnosis and treatment information and to discuss my account*

YesNo

I allow my immunizations records to be released by fax, email or mail to:*

GuardiansSchool

I allow my treatment plan (i.e., medication, asthma, epi-pens, etc.) to be discussed with:*

GuardiansSchool

I allow my office visits to be accessed by:*

GuardiansSchool

I allow my labs to be released to:*

GuardiansSchool

With my consent, I allow any “confidential information” including results of STD testing, HIV, AIDS, and Pregnancy testing to be shared with:*

GuardiansSchool

Signature

You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Guardian 1 Name

Relationship

Guardian 2 Name

Relationship

Date

CONSENT TO USE AND DISCLOSE HEALTH INFORMATION - 18 YEARS AND OLDER

I AUTHORIZE POOLE AND THOMAS PEDIATRICS AND ITS STAFF TO DISCUSS MY MEDICAL INFORMATION AS FOLLOWS