Patient Consent and Acknowledgment of Receipt of Privacy Notice
I understand that as part of the provision of health care services, Texas Thyroid & Endocrine Center, P.A. creates and maintains health records and other information describing among other things, my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment.
I have been provided with a notice of privacy practices that provides a complete description of the uses and disclosures of certain health information and identifiers such as my name, date of birth, insurance card and driver's license, telephone number and address. It also explains how I may amend my medical records, obtain a record of disclosure or file a complaint regarding disclosure of my records. I understand that I have had the right to review the notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations(quality assessment and improvement activities, underwriting, premium rating conducting or arranging for medical review, legal services and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested.
By signing this form, I consent to the use and disclosure of protected health information about me for the purposes of treatment, payment and health care operations this includes calling me for and appointment reminder. I have the right to revoke this consent, in writing, except where disclosures have been made in reliance on my prior consent.
THIS CONSENT IS GIVEN FREELY WITH THE UNDERSTANDING THAT:
- Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed for reasons outside of treatment, payment or health care operations with out my prior written authorization, except as otherwise provided by law.
- A photocopy or fax of this consent is as valid as the original.
- I have the right to request that the use of my Protected Health Information, which is used or disclosed for the purpose of treatment, payment or health operations be restricted. I also understand that Texas Thyroid & Endocrine Center, P.A. And I must:
- agree to any restriction in writing that I request on the use and disclosure of my protected health information and,
- agree to terminate any restriction in writing on the use and disclosure of my Protected Health Information which have be previously agreed upon.