Consent to Release Protected Healthcare Information & Notice of Privacy Practices Acknowledgement

Consent to Release Protected Healthcare Information & Notice of Privacy Practices Acknowledgement
Patient’s Name

First NameLast Name
I authorize New Way Psychiatry and the following persons/agencies listed below to disclose and share confidential information about me. This confidential information includes, but is not limited to:my alcohol and drug use history, psychological/psychiatric history, medical history; family history, legal and
financial status, treatment history, results of diagnostic tests, urine tests, and clinical progress reports; current or planned treatment I may receive; all aspects of my treatment and clinical progress; and, all other information deemed important by New Way Psychiatry to assist with my treatment and/or other personal or business matters including but not limited to insurance reimbursement, legal action, regulatory action, marital conflict, child custody, etc.

I authorize release of this information to and from the following persons, organizations, and/or agencies:
Your psychiatrist, psychologist, or other therapist (specify)
Your Initials
Your medical physician (specify)
Your Initials
Family members: (specify)
Your Initials
Your attorney (specify)
Your Initials
Others (specify):
Your Initials
I acknowledge that this consent can be revoked by me in writing and that I can do so at any time for any reason except to the extent that: (a) this information is deemed necessary to protect my personal*

YesNo
safety and/or the safety of others who may be seriously affected by my behavior; (b) disclosure has already occurred; and, (c) any pending action already taken and/or in progress that relies on this disclosure.
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Notice of Privacy Practices Acknowledgement
Patient’s Name

First NameLast Name
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA),
I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and Provider certifications.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound
to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
Patient’s signature*

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