PREMIER WOMEN'S HEALTH GENERAL CONSENT

PREMIER WOMEN'S HEALTH
General Consent for Treatment and Communication
Name

First NameLast Name
TEATMENT
I consent to treatment and care by Premier Women's Health healthcare providers. I understand that treatment and care may include routine care and a variety of other services such as laboratory tests, imaging, education and/or other procedures depending on my condition. I understand my provider is available to explain the reason(s) for treatment and procedures. I understand I have the right to refuse the recommended treatment

YesNo
DISCLOSURE AND USE OF PHI
I give permission for Premier Women's Health to release information about my health, services and/or payment for health services that may be necessary for treatment. This information can be released to other healthcare providers and facilities for my continued care, for purposes related to payment by me or a third party or for the healthcare operations of Premier Women's Health or another Yes healthcare provider that has a relationship with me.

YesNo
PATIENT PORTAL ACCESS
I consent to access the Premier Women's Health patient portal for the purpose of reviewing my past and future appointments, Yes health records, results, and provider communication.

YesNo
An emailed link should be sent to:
example@example.com
M HEALTH FAIRVIEW NETWORK
Premier Women's Health is part of the M Health Fairview Health Network Accountable Care Organization. I understand information concerning my past, current and future health and account history will be shared by my insurance with Premier Women's Health based on my answer below.

My insurer may share my past, current and future health, and account records with Premier Women's Health about services I have received from Premier Women's Health and other care providers unrelated to Premier Women's Health. These Records may be used by Premier Women's Health to manage or coordinate my careMy insurer may NOT release any identifiable health records as described above.
COMMUNICATION

We may need to call you to communicate PHI and other information to you such as appointment reminders, test results and billing information. Please indicate below how we can contact you with this information and if we can leave a message.
Can we identify ourselves as Premier Women's Health when we call?

YesNo
Cell Phone
CAN WE?

Leave Detailed MessageLeave message to call clinicDo not leave any messages
If you would like to authorize Premier Women's Health to verbally discuss your information (including, but not limited to, appointment schedules, symptoms, diagnosis, medications, lab results and/or billing information) with anyone other than yours elf, please indicate their name, relationship to you and they type of information you will allow us to disclose to them. This does not allow these individuals to obtain copies of your medical or billing records. Revocation of this authorization must be sent, in writing, to Premier Women's Health and does not apply to information that has already been released.
Name
Relationship to you
Medical OnlyFinancial/Billing OnlyMedical and Financial/Billing
Name
Relationship to you
Medical OnlyFinancial Billing OnlyMedical and Financial/Billing
NOTICE OF PRIVACY POLICY ACKNOWLEDGEMENT

I acknowledge that I was shown and/or offered a copy of the Notification of Privacy Practices and know that a copy of the policy can be made available to me upon request. My signature below indicates I have read and understand this General Consent for Treatment and Communication.
Patient Signature

Clear
Date

MonthDayYear
Date
ParentLegal Guardian Print and Sign

Clear
Relationship to Patient
Date

MonthDayYear
Date
Should be Empty:

PREMIER WOMEN'S HEALTH

General Consent for Treatment and Communication

TEATMENT

DISCLOSURE AND USE OF PHI

PATIENT PORTAL ACCESS

M HEALTH FAIRVIEW NETWORK

COMMUNICATION