Patient Consent to the Use and Disclosure of Health Information
for Treatment, Payment, or Healthcare Operations

I understand that as part of my health care, the practice originates 
and maintains paper and/or electronic records describing my health 
history, symptoms, examination and test results, diagnoses, treatment, 
and any plans for future care or treatment. I understand that this 
information serves as:

•	A basis for planning my care and treatment,
•	A means of communication among the health professionals who 
        contribute to my care,
•	A source of information for applying my diagnosis and treatment 
        information to my bill,
•	A means by which a third-party payer can verify that services 
        billed were actually provided, 
•	A tool for routine healthcare operations, such as assessing 
        quality and reviewing the competence of staff

I have been provided the opportunity to review the
 
“Notice of Patient Privacy Information Practices” 

that provides a more complete description of information uses and disclosures.   

I understand that I have the following rights:

•	The right to review the “Notice” prior to acknowledging this consent,
•	The right to restrict or revoke the use or disclosure of my health 
        information for other uses or purposes,   and
•	The right to request restrictions as to how my health information may 
        be used or disclosed to carry out treatment, payment, or health care 
        operations

Restrictions:
I request the following restrictions to the use or disclosure of my health information:
_____________________________________________________________________________________
_____________________________________________________________________________________

May discuss treatment, payment or healthcare operation with the following persons:

(Please check all that apply) 
   
Spouse [  ]  Your Children [  ]   Relatives [  ]   Others [  ]   Parents  [  ]

Please list the names and relationship, if you checked “Relatives” or “Others” above
_____________________________________________________________________________________
_____________________________________________________________________________________   

Messages or Appointment Reminders:  (Please check all that apply)

May we leave a message on your answering machine at home [  ]  or at work [  ].
    Do not leave a message [  ]
May we leave a message with someone at your home using the doctor’s name or the practice name:
    Yes [  ]   No [  ]
May we leave a message with someone at your work using the doctor’s name or the practice name:
    Yes [  ]   No [  ]
Messages will be of a non-sensitive nature, such as, appointment reminders.

I understand that as part of treatment, payment, or healthcare operations, it may become 
necessary to disclose health information to another entity, i.e., referrals to other 
healthcare providers, labs, and/or other individuals or agencies as permitted or required
by state or federal law. 

I fully understand and accept the information provided by this consent.

________________________________________     ___________________
Signature                                    Date

________________________________________				
Print name of person signing

*If other than patient is signing, are you the parent, legal guardian, custodian or have
Power of Attorney for this patient, for treatment, payment or healthcare operations.
     Yes [  ]   No [  ]


FOR OFFICE USE ONLY
[  ]  Patient refused to sign the consent form.
[  ]  Restrictions were added by the patient (see restrictions listed above)
[  ] “ Consent form” received and reviewed by____________________________ 
       on (date) ________________________
[  ]  “Consent form” placed in the patient’s medical record 
       on (date)______________________________