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.
e) 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.
f) 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.
