Patient HIPAA Acknowledgement and Consent Form 2

  • Date Format: MM slash DD slash YYYY
  • Notice of Privacy Practices

  • I acknowledge that I have received the practice's Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice's Notice of Privacy Practices.
  • Release of Information

  • employer's designee when the services delivered are related to a claim under worker's compensation. • If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers of payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. This information may include, without limitation, history and physical, emergency records, laboratory reports, operative reports, physician progress notes, nurse's notes, consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary. • Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as, HIV and AIDS.
  • Disclosures to Friends and/or Family Members

  • I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings, and care decisions to the family members and other listed below:
  • Consent to Email or Text for Appointment Reminders or Other Healthcare Communications:

  • Patients in our practice may be contacted via email and/or text message to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information. If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email or text address from the Practice
  • I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number or emails to receive communications as stated above. I understand that this request to received emails and text messages will apply to all future appointments reminders/feedback/health information unless I request a change in writing (see revocation section below). The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details).
  • Revocation of Consent to Email or Text for Appointment Reminders or Other Healthcare Communications:

  • I hereby revoke my request to receive any future appointment reminders, feedback, and general health via text messages.
  • I hereby revoke my request to receive any future appointment reminders, feedback, and general health via email.
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  • Consent for Photographing or Other Recording for Security and/or Health Care Operations

  • I consent to photographs, videotapes, digital and audio recordings, and/or images of me being recorded for security purposes and/or the practice's health care operations purposes (e.g. quality improvement activities). I understand that the facility retains ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not released and/or used without specific written authorization from me or my legal representative unless it is for treatment, payment, or healthcare operations purposes or otherwise permitted or required by law.
  • I do not consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for security purposes and/or the practice's health care operations purposes (e.g. quality improvement activities).
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY