Type NA if the question does not apply to you.
Our Notice of Privacy Practices provides information about how we may use ancl disclose protected health information (PHI) about you. We provide this form to comply with the Health Insurance Portability and Accountability Act (HIPAA). Please review the Notice of Privacy Practices thoroughly before signing this acknowleclgement form. lfterms of our Notice change, a revised copy will be made available to you.
By signing this form, you acknowledge that our practice may use and disclose PHI about you for treatment, payment and healthcare operations. You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment or healthcare operations.
Consent to email or text for appointment reminders and other healthcare communication.
If you approve, we may contact you via email and/or text messaging to remind you of an appointment or provide general health reminders or information.
I understand that once I have consented to receive communications via text or email, I still have the right to revoke the consent at any time.
CONSENT FOR USE / DISCLOSURE OF HEALTH INFORMATION
Notice to Patient:
By signing this form, you grant us consent to use and disclose your protected health care information for the purposes of treatment, various activities associated with payment and health care operations.
Our Notice of Privacy Practices provides more details on our treatment, payment activities and health care operations. If there is not a copy of the Notice accompanying this Consent form, please ask for one. We encourage you to read it since it provides details on how information about you may be used and/or disclosed and describes certain rights you have regarding your health care information.
As stated in our Notice of Privacy Practices, we reserve the right to change our privacy practices.
If we should do so, we will issue a revised Notice. Since revisions may apply to your health care information, you have a right to receive a copy by contacting our Privacy Officer.
You have the right to revoke your Consent by giving written notice to our Privacy Officer. The revocation will not affect actions that were already taken in reliance upon this Consent. You should also understand that if you revoke this Consent we may decline to treat you.
You are entitled to a copy of this Consent Form after you have signed it.
(To Be Completed by Patient or Patient’s Representative)
I have read the contents of this Consent Form and the Notice of Privacy Practices.
I understand that I am giving you my consent to use and disclose my health care information to carry out treatment, payment activities and health care operations.
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
TO REQUEST RELEASE OF MEDICAL INFORMATION PLEASE COMPLETE AND SIGN BELOW
1. I understand that this authorization will expire on (one year from today’s date)
2. I understand that I may revoke this authorization (except to the extent that action was already taken in reliance on this signed authorization) at any time by notifying NUBY PEDIATRICS in writing.
3. I understand that I can refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment, or my eligibility of benefits (if applicable)
4. I may inspect or copy any information used or disclosed under this agreement.
I understand that if the person or organization that receives the information is not a health care provider or plan covered by the federal privacy law and regulations, the information described above may be redisclosed and would no longer be protected by these regulations.
Click submit and you hereby give consent to sign this document electronically.
