LEGAL GUARDIAN OTHER THAN BIOLOGICAL PARENT
***MUST HAVE LEGAL DOCUMENTATION SHOWING GUARDIANSHIP***
Please read the following carefully and initial in spaces provided
Do any family members have any of the following conditions? If so, mark the box for condition and which family member is affected.
Who lives in the household with the child?
Please name your previous pediatrician or name of the facility with phone number, address and fax number if available.
Please list all current medications with dosage and directions or check below if there are no current medications.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES/ USE AND DISCLOSURE FORM
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.
Revocation - Use this area to document revocation of a previous form of communication.
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.
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
TO REQUEST RELEASE OF MEDICAL INFORMATION PLEASE COMPLETE AND SIGN BELOW
The information is to be provided to:
VERY IMPORTANT! PLEASE READ!
• HIP AA stands for the Health Insurance Portability and Accountability Act
• HIPAA was passed by the U.S. government in 1996 ln order to establish privacy and security protections for health information
• Information stored on our computers is encrypted
• Most popular email services (ex. Hotmail, Gmail, Yahoo) do not utilize encrypted email
• When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet.
In addition, once the email is received by you, someone may be able to access your email account and read it.
• Email is a very popular and convenient way to communicate for a lot of people, so in their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA
• The information is available in a pdf (page 5634) on the U.S. Department of Health and Human Services website
• The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email
Click submit and you hereby give consent to sign this document electronically.