aspire4w.com - HIPAA Acknowledgement

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
UNLESS WE HAVE YOUR WRITTEN PERMISSION TO DO SO, we will not leave messages on any voicemail/answering machine or with anyone other than you or your legal guardian regarding your health information with the exception of reminding you of an appointment. Please read below and consider carefully whom you want to have access to your medical information.

I, , give OB/GYN Affiliates my permission to discuss my medical care or leave phone messages regarding my medical care with the following people using the following contact information. I understand that medical care includes my health information, laboratory results, test results and/or financial information. I fully understand that this consent will remain valid until revoked in writing.

Myself at my Home / Answering Machine: #

Myself on my Cell Phone / Voice Mail: #

Myself at my Office / Work Voice Mail: #

Name:

Relationship:

Phone Number

Please enter a valid phone number.

Name:

Relationship:

Phone Number

Please enter a valid phone number.

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES
I affirm that I have received or read the HIPAA policies of OB/GYN Affiliates including the Notice of Privacy Practices. I understand that I have the right to request restrictions on the use and disclosures of my health information and that I have the right to revoke this consent in writing.

RELEASE OF BILLING INFORMATION
I authorize OB/GYN Affiliates to release any medical information to such private insurance, the Centers for Medicare & Medicaid Services and/or any other health plan to the extent such information is needed to determine benefits or benefits payable for related services.

ASSIGNMENT OF BENEFITS
I hereby assign all medical, surgical, and/or third party payer benefits to which I am entitled, including private insurance, Medicare and/or any other health plan to: OB/GYN Affiliates for any services furnished me by OB/GYN Affiliates.

MEDICATION HISTORY CONSENT
I authorize OB/GYN Affiliates to access and download an historic list of all medications prescribed to me by any provider over the past 13 months for the purpose of improving care and enhancing patient safety.

HIV TESTING CONSENT
I consent to having an HIV test ordered if I am an obstetrical patient. If I am not an obstetrical patient, I consent to having an HIV test ordered at my request or in the event that my provider feels that it is medically necessary.

MARKETING INFORMATION
OB/GYN Affiliates does not provide information to 3rd party marketing companies. OB/GYN Affiliates does use our patient addresses to provide information to our patients of our services and new services, that our offered, as well as, introduction of new staff, and internal changes that may affect patients, in accordance with current HIPAA Privacy Practices, 45 CFR 164.501,
164.508(a)(3).

Unless otherwise indicated above, my signature below represents my consent to all of the above statements and any questions that I had have been answered to my satisfaction.

PATIENT NAME

SIGNATURE OF PATIENT/GUARDIAN

DATE

Date

OB/GYN Affiliates

OTHER