Patient Consent For Use & Disclosure of PHI

Please correct the errors described below.

With my consent, Drs. Kartsonis, McClintock, and Hurt and their staff at Dermatology Specialists of North Florida, P.A. (DSNF) may use and disclose my protected health information (PHI) to carry out treatment, payment and healthcare operations (TPO). Please refer to our 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. DSNF reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Officer at 7711 Baymeadows Road E., Ste. 6; Jacksonville, FL 32256.

With my consent, DSNF may text, call, mail or email my home or other designated location and leave a message on voice mail 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, DSNF may disclose PHI to me, my spouse or representative that I have listed in my Medical Record. I have the right to request that DSNF 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.

PATIENT CONSENT TO RECEIVE PRACTICE, SERVICE AND PRODUCT UPDATES

With my consent, DSNF may communicate practice, product and service information to me.

PATIENT CONSENT TO OBTAIN EXTERNAL PRESCIPTION HISTORY

With my consent, DSNF may view my external prescription history via the EClinicalWorks electronic service as part of my care.

I understand that prescription history from multiple other unaffiliated medical providers, insurance companies and pharmacy benefit managers may be viewable by the Practice’s staff and it may include prescriptions back in time for several years.

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, DSNF may decline to provide treatment to me.

MY SIGNATURE BELOW CERTIFIES THAT I HAVE READ AND UNDERSTAND THE SCOPE OF MY CONSENT AND THAT I AUTHORIZE THE UTILIZATION OF THIS DATA FOR MY CARE. THIS CONSENT IS VALID FOR ONE YEAR FROM THE DATE OF MY SIGNATURE.

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.

Your message will be encrypted.