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.
hereby authorize and consent to the examination and/or treatment during office and facility visits by the physicians and clinical staff of Poole & Thomas Pediatrics.
By signing below, I authorize Poole & Thomas Pediatrics to release my medical and billing information to:
INITIAL ALL THAT APPLY
If there is ever a change in this request, please notify the staff of Poole and Thomas Pediatrics.
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:
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:
I acknowledge that I have received the Consent to Use & Disclose Health Information, which explains how my health information will be handled in various situations
At Poole and Thomas Pediatrics, we are committed to protecting the security and privacy of your child’s personal information. Medical records are the property of Poole and Thomas Pediatrics. These records are kept in a secure location, and are accessed only for the purposes outlined by the Notice of Privacy Practices (Revised 9/23/13). Our revised Privacy Notice is available at www.ptpediatrics.com , or you may request a copy from our office. Records may be released or shared with other healthcare professionals for the treatment of your child. Patients are entitled to one free copy of their medical records only after an authorization for release is signed. Additional copies may be made for a fee of $1.00 per page, per KY House Bill 250.
My signature below indicates I am the patient listed above, that I have provided accurate information to the best of my knowledge and I understand and agree to the provision above.
Your information will be encrypted.