PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

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With my consent, Zaladonis Dermatology Associates may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Zaladonis Dermatology Associates’ Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. Zaladonis Dermatology Associates reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy of Practices may be obtained by forwarding a written request to Zaladonis Dermatology Associates, Privacy Officer at 1665 Valley Center Parkway, Suite 120, Bethlehem, PA 18017. With my consent, Zaladonis Dermatology Associates may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. With my consent, Zaladonis Dermatology Associates may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. I have the right to request that Zaladonis Dermatology Associates restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Zaladonis Dermatology Associates use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Zaladonis Dermatology Associates may decline to provide treatment to me. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM.

I, (indicate name below) have received a copy of Zaladonis Dermatology Associates’ Notice of Privacy Practices. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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