SFM PHI Consent

Date

Patient Name

First NameMiddle Name or InitialLast Name

Patient Date of Birth

Date

Responsible Party (if not the Patient)

First NameMiddle Name or InitialLast Name

If Responsible Party, Relationship to Patient

Email

example@example.com

Primary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

To comply with state and federal law concerning the disclosure of protected health informatoin (PHI), Sparks Family Medicine, Ltd. requires that you indicate how PHI should be communicated to you or your personal representative. SFM provides a secure patient portal for the exchange of messages and documents. The patient portal is the default method of sharing PHI between SFM and you.

For your convenience, please indicate if you would like to OPT IN to having your PHI, such as lab results, imaging studies, visit follow ups), communicated to you using the following methods. I understand that the PHI disclosed will be minimal, such as first name, the name of our office, results of either "normal" or "abnormal", basic treatment result data), appointment dates and times, and our contact information.

Your portal email and preferred contact phone will be used.

Permission to communicate minimal PHI by:

Rows	1st Choice	2nd Choice	3rd Choice	Do Not Use
Phone
Text
Email

PHI patient authorization for individuals:

Add each authorized individual's name and phone and/or email:

Your rights as outlined in the Notice of Privacy Practices provided by this office online, (or, if requested, on paper), are still protected, regardless of how you choose for PHI to be communicated to you or your personal representative. This consent will remain in effect unless changed, in writing, by you our your personal representative.

Acknowledgement:

By signing below, patient or patient's representative acknowledges that they have reviewed the above SFM Patient Information forms, (Protected Health Information Consent, Financial Policy Agreement, Patient Rights and Responsibilities Agreement, Adjust Therapy Informed Consent, Telemedicine Informed Consent, Messaging Policy Consent Form, Long-Term Controlled Substances Agreement and Patient Acknowledgement of Privacy Practices), and that they both understand and agree to their content.

Name of Person Signing this Form

First NameMiddle Name or InitialLast Name

Electronic Signature Acknowledgement and Consent

Authorization to Receive Password Protected Attachment

Signature