PATIENT CONSENT
By signing below, I hereby acknowledge, agree, and authorize all of the following:
A) Accurate Information. I certify that the information provided on this form is
accurate, complete, and up to date to the best of my knowledge.
B) Patient Rights and Responsibilities. I understand that the healthcare facility
maintains a Notice of Privacy Practices, which describes how my protected
health information may be used and disclosed, and how I may access my health
records. I understand that I have the right to review this healthcare facility’s
Notice of Privacy Practices prior to signing this form.
C) Release of Medical Information. I authorize the release of my health
information to the healthcare facility in accordance with the healthcare facility’s
Notice of Privacy Practices. This includes, but is not limited to, releasing medical
information to my referring physician, primary care physician, and any
physician(s) I may be referred to. The healthcare facility shall ensure all health
information remains confidential, as required by HIPAA, and will not release any
of my health information without my consent.
D) Consent for Treatment. I grant the healthcare facility, including its affiliated
providers, physicians, and other medical personnel, permission to use the health
information provided for the purpose of my medical treatment as necessary.
Consent to Communication. I consent to receiving communications from the
healthcare facility regarding appointment reminders, test results, and other
necessary healthcare-related information via phone, email, or channels.
E) Acknowledgment. By signing below, I hereby acknowledge, agree, and
authorize all of the above, and I authorize the healthcare facility to retrieve and
review my medical history and authorize the healthcare facility to release the
information required in obtaining procedure authorization or the processing of
any insurance claims.
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