HIPAA Consent Form

I hereby give my consent for MD4Kidz Pediatric Group, P.A. to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by MD4Kidz Pediatric Group, P.A. describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. MD4Kidz Pediatric Group, P.A. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to MD4Kidz Pediatric Group, P.A., 34 Corbett Way, Eatontown, NJ 07724.

With this consent, MD4Kidz Pediatric Group, P.A. may call my home or other alternative 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 calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, MD4Kidz Pediatric Group, P.A. may mail to my home or other alternative 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.”

With this consent, MD4Kidz Pediatric Group, P.A. may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that MD4Kidz Pediatric Group, P.A. restrict how it uses or discloses my PHI to carry out TPO. 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 allow MD4Kidz Pediatric Group, P.A. to use and disclose 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, or later revoke it, MD4Kidz Pediatric Group, P.A. may decline to provide treatment to me.

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