Consent To Use And Disclose Health Information

18 Years And Older

Please correct the errors described below.

This office is required by Federal Regulations to inform our patients to the use of your health information accordance to Health Information Portability and Accountability Act or HIPAA.

I understand that as a part of my health care, Poole and Thomas Pediatrics originates and maintains paper records describing my health history, symptoms, examinations, test results, diagnosis, treatments, 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 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 can verify the services billed to me actually took place.

I understand and have been provided access to a Notice of Privacy Practices that provide a more complete description of information uses and disclosures. This notice is located on our website ptpediatrics.com and is located in paper form at the check-in window of our office. I understand that I have the following rights and privileges:

  • The right to review the Notice of Privacy Practices prior to signing this consent, allowing treatment, or making payment for services rendered and the right to a paper copy of the Notice of Privacy Practices.
  • The right to object to the use of my health information for directory purposes.
  • The right to request confidential communications.

I AUTHORIZE POOLE AND THOMAS PEDIATRICS AND ITS STAFF TO DISCUSS MY MEDICAL INFORMATION AS FOLLOWS

INITIAL ALL THAT APPLY

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DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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